Scaling-up Bibliography
The ExpandNet bibliography includes publications, websites, grey literature, and conference reports that either directly address scaling up or provide valuable insights on scaling up. Included are materials from a range of global health and development technical areas as well as the various sciences relevant to scale up. The references below are useful, but not exhaustive, and not the result of a systematic search process. If you would like us to consider including an additional reference, please contact us.
All references in the bibliography are grouped by topic below. To jump to down to view references related primarily to a specific topic, use the navigation links below. To create a personalized search, use the search and filtering box at left. Please note that using the search function will provide more robust results than the below navigation links below since some references span across multiple topic areas (i.e. Scaling-up theories, frameworks and concepts AND Family planning).
- Scaling-up Theories, Frameworks, and Concepts
- Tools to Support Scale Up
- Implementation Science
- Research Utilization
- Adaptation, Adaptive Management, Complexity and Fidelity
- Country Government Ownership
- Sustainability
- Health Financing and Costs
- Monitoring and Evaluation of Scale Up
- Health - General
- Family Planning
- Sexual and Reproductive Health
- Gender and Social Norms
- Adolescent Sexual and Reproductive Health
- Maternal, Neonatal, Child Health
- Nutrition
- STIs, HIV/AIDS
- Malaria and TB
- Primary Health Care
- Community Health and Community Health Workers
- m-Health
- Universal Access to Health Care
- Development - General
- Youth
- Education
- Agriculture and Environment
- Water and Sanitation
Scaling-up Theories, Frameworks, and Concepts
The Bank Group achieves this objective by: mobilizing and allocating resources for investment in RMCs; and
providing policy advice and technical assistance to support development efforts.
In 2015, all multilateral development institutions have agreed on a same set of objectives, called the Sustainable Development Goals.
Careful consideration and planning are required to establish “sufficient” evidence to ensure an investment in a larger, more well-powered behavioral intervention trial is worthwhile. In the behavioral sciences, this process typically occurs where smaller-scale studies inform larger-scale trials. Believing that one can do the same things and expect the same outcomes in a larger-scale trial that were done in a smaller-scale preliminary study (i.e., pilot/feasibility) is wishful thinking, yet common practice. Starting small makes sense, but small studies come with big decisions that can influence the usefulness of the evidence designed to inform decisions about moving forward with a larger-scale trial. The purpose of this commentary is to discuss what may constitute sufficient evidence for moving forward to a definitive trial. The discussion focuses on challenges often encountered when conducting pilot/feasibility studies, referred to as common (mis)steps, that can lead to inflated estimates of both feasibility and efficacy, and how the intentional design and execution of one or more, often small, pilot/ feasibility studies can play a central role in developing an intervention that scales beyond a highly localized context.
Main body: Establishing sufficient evidence to support larger-scale, definitive trials, from smaller studies, is complicated. For any given behavioral intervention, the type and amount of evidence necessary to be deemed sufficient is inherently variable and can range anywhere from qualitative interviews of individuals representative of the target population to a small-scale randomized trial that mimics the anticipated larger-scale trial. Major challenges and common (mis)steps in the execution of pilot/feasibility studies discussed are those focused on selecting the right sample size, issues with scaling, adaptations and their influence on the preliminary feasibility and efficacy estimates observed, as well as the growing pains of progressing from small to large samples. Finally, funding and resource constraints for conducting informative pilot/feasibility study(ies) are discussed.
Conclusion: Sufficient evidence to scale will always remain in the eye of the beholder. An understanding of how to design informative small pilot/feasibility studies can assist in speeding up incremental science (where everything needs to be piloted) while slowing down premature scale-up (where any evidence is sufficient for scaling).
Keywords: Scaling, Translation, Intervention, Pilot, Feasibility, Early-stage
Knowledge syntheses that use a realist methodology are gaining popularity. Yet, there are few reports in the literature that describe how results are summarised, shared and used. This paper aims to inform knowledge translation (KT) for realist reviews by describing the process of developing a KT strategy for a review on pathways for scaling up complex public health interventions.
Methods
The participatory approach used for the realist review was also used to develop the KT strategy. The approach included three main steps, namely (1) an international meeting focused on interpreting preliminary findings from the realist review and seeking input on KT activities; (2) a targeted literature review on KT for realist reviews; and (3) consultations with primary knowledge users of the review.
Results
The international meeting identified a general preference among knowledge users for findings from the review that are action oriented. A need was also identified for understanding how to tailor findings for specific knowledge user groups in relation to their needs. The literature review identified four papers that included brief descriptions of planned or actual KT activities for specific research studies; however, information was minimal on what KT activities or products work for whom, under what conditions and why. The consultations revealed that KT for realist reviews should consider the following: (1) activities closely aligned with the preferences of specific knowledge user groups; (2) key findings that are sensitive to factors within the knowledge user’s context; and (3) actionable statements that can advance KT goals, activities or products. The KT strategy derived from the three activities includes a planning framework and tailored KT activities that address preferences of knowledge users for findings that are action oriented and context relevant.
Conclusions
This paper provides an example of a KT strategy for realist reviews that blends theoretical and practical insights. Evaluation of the strategy’s implementation will provide useful insights on its effectiveness and potential for broader application.
Many family health innovations that have been shown to be both efficacious and cost-effective fail to scale up for widespread use particularly in low-income and middle-income countries (LMIC). Although individual cases of successful scale-up, in which widespread take up occurs, have been described, we lack an integrated and practical model of scale-up that may be applicable to a wide range of public health innovations in LMIC.
Objective:
To develop an integrated and practical model of scale-up that synthesises experiences of family health programmes in LMICs.
Data sources: We conducted a mixed methods study that included in-depth interviews with 33 key informants and a systematic review of peer-reviewed and grey literature from 11 electronic databases and 20 global health agency web sites. Study eligibility criteria, participants and interventions: We included key informants and studies that reported on the scale up of several family health innovations including Depo-Provera as an example of a product innovation, exclusive breastfeeding as an example of a health behaviour innovation, community health workers (CHWs) as an example of an organisational innovation and social marketing as an example of a business model innovation. Key informants were drawn from non-governmental, government and international organisations using snowball sampling. An article was excluded if the article: did not meet the study's definition of the innovation; did not address dissemination, diffusion, scale up or sustainability of the innovation; did not address low-income or middle-income countries; was superficial in its discussion and/or did not provide empirical evidence about scale-up of the innovation; was not available online in full text; or was not available in English, French, Spanish or Portuguese, resulting in a final sample of 41 peer-reviewed articles and 30 grey literature sources.
The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda.
Methods
The study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention.
Results
A shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up.
Conclusions
Despite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.
This volume captures some of the diversity of views and experiences within that community. Chapter authors include academics and practitioners, and among the latter, representatives of the public and private sectors. Some chapters contain personal accounts of success and failure; others offer rigorous analysis of what those in the field have been able to accomplish.
While there is a wealth of ideas and experience packed into this volume, reflecting a decade of learning, our understanding of how to bring successful development interventions to scale remains limited. The editors hope that this work will spur further research, analysis, and experimentation to answer this question, which is pivotal to understanding how development cooperation, in all its forms, can have an impact commensurate with the scale of the challenges to be addressed.
The volume is the outcome of an eighteen-month collaborative project between the Brookings Institution and the Japan International Cooperation Agency (JICA). Earlier drafts of the volume's chapters were discussed at a two- day workshop held in Washington, D.C., in January 2012. The editors are
This paper draws on the growing scaling literature and practice and on the work of the Scaling Community of Practice over the decade of its existence. It presents a framework primarily for public sector-driven scaling by looking at scaling through three different lenses: (i) the scaling pathway from innovation to sustainable impact at scale; (ii) the relationship between scaling and system change in the pursuit of sustainable impact at scale; and (iii) implications for the prevailing project-based approaches. The paper then consolidates these three perspectives in a holistic approach to scaling that incorporates relevant aspects of systems change and the dynamics of operating in a project world. The paper concludes with a set of core questions for practitioners.
Digital health innovations can improve health system performance, yet previous experience has shown that many innovations do not advance beyond the pilot stage to achieve scale. Vietnam’s National Immunization Information System (NIIS) began as a series of digital health pilots, first initiated in 2010, and was officially launched nationwide in 2017. The NIIS is one of the few examples of an electronic immunization registry (EIR) at national scale in low- and middle-income countries.
Objective:
The aim of this study was to understand the determinants of scale-up of the national EIR in Vietnam.
Methods:
This qualitative study explored the facilitators and barriers to national scale-up of the EIR in Vietnam. Qualitative data were collected from October to December 2019 through in-depth key informant interviews and desk review. The mHealth Assessment and Planning for Scale (MAPS) Toolkit guided the development of the study design, interview guides, and analytic framework. MAPS defines the key determinants of success, or the “axes of scale,” to be groundwork, partnerships, financial health, technology and architecture, operations, and monitoring and evaluation.
Results:
The partnership and operations axes were critical to the successful scale-up of the EIR in Vietnam, while the groundwork and monitoring and the evaluation axes were considered to be strong contributors in the success of all the other axes. The partnership model leveraged complementary strengths of the technical working group partners: the Ministry of Health General Department of Preventive Medicine, the National Expanded Program on Immunization, Viettel (the mobile network operator), and PATH. The operational approach to introducing the NIIS with lean, iterative, and integrated training and supervision was also a key facilitator to successful scale-up. The financial health, technology and architecture, and operations axes were identified as barriers to successful deployment and scale-up. Key barriers to scale-up included insufficient estimates of operational costs, unanticipated volume of data storage and transmission, lack of a national ID to support interoperability, and operational challenges among end users. Overall, the multiple phases of EIR deployment and scale-up from 2010 to 2017 allowed for continuous learning and improvement that strengthened all the axes and contributed to successful scale-up.
Conclusions:
The results highlight the importance of the measured, iterative approach that was taken to gradually expand a series of small pilots to nationwide scale. The findings from this study can be used to inform other countries considering, introducing, or in the process of scaling an EIR or other digital health innovations.
Given the increased investment in humanitarian innovation, however, we may expect to start seeing significant numbers of innovations beginning to achieve scale. Although we are seeing some examples of innovations that are scaling or have scaled, in the main this is not the case. This is because:
There are significant barriers to scale in the humanitarian sector which are inhibiting innovations reaching their full potential. These barriers increase the time, effort and financial investment required to scale, and are preventing the type of transformative change we want to see.
The need to address these barriers is therefore critical. Not only does the humanitarian system urgently require the development of robust new solutions to make limited resources more effective, but it also needs to ensure that the limited resources targeted at innovation are used effectively and achieve the expected impact.
This report presents the key barriers to scale at both an operational and systemic level. These are grouped into five broad challenge areas for clarity. At the end of each challenge, we describe how the humanitarian sector is currently tackling the challenge and give clear calls to action for key humanitarian actors at both operational and systemic levels. We end each challenge with a set of questions to reflect on.
Globally, by 2050, an estimated 7 of 10 people will likely live in urban areas, most in low- and middle-income countries (LMICs), where the pace of urbanization is projected to be the fastest. In this growing urban population, some of the poorest and least well-served are in informal settlements, which have typically lacked infrastructure and received few city resources.6 However, while the evidence is limited or mixed, the ongoing trend of political decentralization—shifting the decision-making authorities from the national government to the subnational governments—in LMICs could improve health system performance and outcomes in some settings.7–9 Helping cities and other subnational governments to achieve sustainable urbanization, and particularly to respond to the health needs of their most marginalized community members, is critical to successful development outcomes.
There is increasing global recognition of the human right to decide whether, when, and how many children to have. At the same time, investing in and scaling upaccess to contraception for women and girls—particularly married and unmarried individuals ages 15–24 years living in Africa and Asia—brings rich social, economic, educational, and environmental returns and proven reductions in women’s, children’s, and infant morbidity and mortality.10,11
To that end, The Challenge Initiative (TCI) partnered with local governments in various countries to take proven interventions and strategies to scale with local governments taking the lead by not only identifying the interventions that were most needed in their context but also committing human and financial resources from the beginning to enhance the likelihood of sustained impact. Funded by The Bill & Melinda Gates Foundation, Bayer AG, and Comic Relief, TCI covered 106 localities in 10 countries across 4 regions between 2016 and 2021.
The articles in this supplement provide important new evidence, collective experiences, good practices, and lessons learned about the strategies for helping local governments to sustainably scale access to FP for women, youth, and adolescents and to improve access to and use of contraception among adolescents and youth (AY). In this supplement, we present lessons for 2 broad audiences: those interested in the scale and sustainability of FP and other related health and development interventions and those interested in advancing understanding of scaling AY sexual and reproductive health (AYSRH) programming, with a particular focus on contraception.
The global health community continues to face barriers in scaling up evidence-based interventions for widespread adoption. Although many effective interventions have been developed over the years, expanding their reach to benefit broader populations has happened slowly or not at all.
Overview:
The Challenge Initiative (TCI) is a nontraditional development platform that supports local urban governments to rapidly scale up proven family planning (FP) and adolescent and youth sexual and reproductive health (AYSRH) interventions for the urban poor. TCI prioritizes sustainability and local ownership and uses a health systems approach when planning for and managing scale. TCI strengthens urban health systems with seed funding, coaching, and technical assistance (TA), and TCI University houses “how-to” guidance and tools for implementing the interventions. In turn, local governments commit political will and financial and human resources while using TCI coaching to integrate interventions into routine practice and systems to achieve widespread and sustained impact at scale.
Results:
As of June 2021, TCI has supported 104 local governments across 11 countries in scaling up effective FP and AYSRH interventions, while also mobilizing about US$28 million from those local governments to facilitate their implementation. TCI has increased capacity and bolstered urban health systems, with 39 local governments “graduating” from TCI support and 2.02 million additional FP clients across 4 regional TA hubs.
Conclusion:
TCI aims to change how local governments coordinate, finance, and implement proven interventions to improve access to quality FP information and services. With built-in incentives for local governments, partners, and donors to participate, TCI is generating significant learning on how local governments can realize sustainable scale and demonstrating how organizations like TCI that facilitate governments to scale up effective interventions can accelerate the scale-up of these interventions across multiple geographies.
The improvement collaborative approach has been widely promoted in developed countries as an effective method to spread clinical practices, but little has been published on its effectiveness in developing country settings. Between 1998 and 2008, the United States Agency for International Development funded 54 collaboratives in 14 low- and middle-income countries, adapting the approach to resource-constrained environments.
Methods:
The authors analysed data on provider compliance with standards and outcomes from 27 collaboratives in 12 countries that met study inclusion criteria (at least 12 months of data available for analysis and indicators measured as percentages). The dataset, representing 1338 facility-based teams, consisted of 135 time-series charts related to maternal, newborn and child health, HIV/AIDS, family planning, malaria and tuberculosis. An average of 28 months of data was available for each chart.
Results:
Eighty-seven per cent of these charts achieved performance levels of 80% or higher, and 76% reached at least 90% performance, even though two-thirds had a baseline performance below 50%. Teams achieved average increases of 51.9 percentage points (SE¼28.0) per chart, with baseline value being the main determinant of absolute increase. Teams consistently maintained this level of performance for an average of 13 months (69% of months of observation). The average time to reach 80% performance was 9.2 months (SE 8.5), and to reach 90% performance, 14.4 months (SE¼12.0).
Conclusion:
Collaborative improvement can produce significant, sustained gains in compliance with standards and outcomes in less-developed settings and merits wider application as a strategy for health systems strengthening.
We identified factors mentioned in 18 interviews with GEF Secretariat teams and GEF Agencies at the corporate level. We then validated these factors using 20 cases built primarily from document reviews, supported by evidence from an additional 40 cases. Six of the cases involved field visits and interviews specifically to assess whether or not--and how--scaling activities were sustained post-GEF support. Each case consisted of one or more linked projects.
The Global Environment Facility’s (GEF’s) focus on scaling is more explicit than in many other international development institutions. But like other institutions, the GEF’s vision for scaling-up is not consistently clear in operational guidance across its portfolio.
GEF support to scaling-up activities has varied widely in terms of grant amount, implementation period, and project modality. Overall, GEF-supported initiatives typically last longer than five years and leverage higher cofinancing ratios at the scaling-up stage.
The GEF has contributed to postproject continuation of scaled-up activities by catalyzing sustainable financing sources and strengthening institutional capacities. Political and economic changes pose risks to long-term sustainability of scaling-up activities.
The GEF’s comparative advantage lies in supporting pilots that demonstrate positive benefits and establishing enabling conditions for scale-up. These strengths attract support from other actors that then provide funding for full scale-up.
Cases generally reported a higher magnitude of environmental outcomes per dollar per year during scale-up versus piloting. The extent of scaling could not be measured in one case because common environmental indicators were lacking between pilot and scaling projects.
The GEF partnership benefits from its Agencies having different comparative advantages in different modes of scaling.
In 2018, we at the GEF IEO examined how impact is scaled up across different types of environmental interventions funded by the GEF. We looked at 20 cases in-depth, supported by evidence from an additional 40 cases, to assess which factors mattered the most in whether something was scaled up or not. It turns out that what matters for scaling up impact is very similar to what makes an intervention successful or not to begin with.
In 12 out of 20 cases that experienced some political or economic shift during project implementation or scaling-up, two things made a difference: high political priority given to the intervention by supporting institutions, and ownership by long-term staff in these institutions.
How do we reduce the negative effects of such changes – and maybe even turn them into “lucky” positive outcomes? In the previous post, we talked about how contextual factors such as high political priority and a sense of ownership among key stakeholders can be developed through program activities, thus catalyzing support that can weather these changes.
In this post, we discuss how sometimes the solution is not in more program activities, but in using the existing context to your advantage: first, by choosing the right institutions and individuals to partner with, and second, by leveraging current priorities and trends to align with your program’s target outcomes.
Keywords: Health priorities/organization and administration; Delivery of health care/organization and administration; Condoms; Social marketing; Directly observed therapy; Tuberculosis, HIV infections/prevention and control; Multidrug-resistant/prevention and control; Models, Theoretical; Developing countries
Keywords Scaling up framework
· Implementation
· ExpandNet
· E2A
· Family planning
· Capacity building
· Country ownership
· Mindset
Keywords: scaling up of services, pilot projects, health policy and programmes, population, health and environment, scale, development, WHO Strategic Approach, Kenya, Uganda
The lack of a reporting guideline for scaling of evidence-based practices (EBPs) studies has prompted the registration of the Standards for reporting studies assessing the impact of scaling strategies of EBPs (SUCCEED) with EQUATOR Network. The development of SUCCEED will be guided by the following main steps recommended for developing health research reporting guidelines.
Methods
Executive Committee. We established a committee composed of members of the core research team and of an advisory group. Systematic review. The protocol was registered with the Open Science Framework on 29 November 2019 (https://osf.io/vcwfx/). We will include reporting guidelines or other reports that may include items relevant to studies assessing the impact of scaling strategies. We will search the following electronic databases: EMBASE, PsycINFO, Cochrane Library, CINAHL, Web of Science, from inception. In addition, we will systematically search websites of EQUATOR and other relevant organizations. Experts in the field of reporting guidelines will also be contacted. Study selection and data extraction will be conducted independently by two reviewers. A narrative analysis will be conducted to compile a list of items for the Delphi exercise. Consensus process. We will invite panelists with expertise in: development of relevant reporting guidelines, methodologists, content experts, patient/member of the public, implementers, journal editors, and funders. We anticipated that three rounds of web-based Delphi consensus will be needed for an acceptable degree of agreement. We will use a 9-point scale (1 = extremely irrelevant to 9 = extremely relevant). Participants’ response will be categorized as irrelevant (1–3), equivocal (4–6) and relevant (7–9). For each item, the consensus is reached if at least 80% of the participants’ votes fall within the same category. The list of items from the final round will be discussed at face-to-face consensus meeting. Guideline validation. Participants will be authors of scaling studies. We will collect quantitative (questionnaire) and qualitative (semi-structured interview) data. Descriptive analyses will be conducted on quantitative data and constant comparative techniques on qualitative data.
Discussion
Essential items for reporting scaling studies will contribute to better reporting of scaling studies and facilitate the transparency and scaling of evidence-based health interventions.
The recommendations and conclusions give guidelines on how to proceed with scaling up processes.
Spread (replicating an intervention) and scale-up (building infrastructure to support full scale implementation) are difficult Implementation science takes a structured and phased approach to developing, replicating, and evaluating an intervention in multiple sites Complexity science encourages a flexible and adaptive approach to change in a dynamic, self organising system Social science approaches consider why people act in the way they do, especially the organisational and wider social forces that shape and constrain people’s actions These approaches may be used in combination to tackle the challenges of spread and scale-up
System-wide scale up of evidence-based practice (EBP) is a complex process. Yet, few strategic approaches exist to support EBP implementation and sustainment across a service system. Building on the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework, we developed and are testing the Interagency Collaborative Team (ICT) process model to implement an evidence-based child neglect intervention (i.e., SafeCare®) within a large children\'s service system. The ICT model emphasizes the role of local agency collaborations in creating structural supports for successful implementation.
Methods:
We describe the ICT model and present preliminary qualitative results from use of the implementation model in one large scale EBP implementation. Qualitative interviews were conducted to assess challenges in building system, organization, and home visitor collaboration and capacity to implement the EBP. Data collection and analysis centered on EBP implementation issues, as well as the experiences of home visitors under the ICT model.
Results:
Six notable issues relating to implementation process emerged from participant interviews, including: (a) initial commitment and collaboration among stakeholders, (b) leadership, (c) communication, (d) practice fit with local context, (e) ongoing negotiation and problem solving, and (f) early successes. These issues highlight strengths and areas for development in the ICT model.
Conclusions:
Use of the ICT model led to sustained and widespread use of SafeCare in one large county. Although some aspects of the implementation model may benefit from enhancement, qualitative findings suggest that the ICT process generates strong structural supports for implementation and creates conditions in which tensions between EBP structure and local contextual variations can be resolved in ways that support the expansion and maintenance of an EBP while preserving potential for public health benefit.
Keywords: Evidence-based practice; Implementation; Process Model; Sustainment; Teams.
How do social entrepreneurs and the funders who support them scale solutions to widespread problems, such as poverty and climate change? The Innovation Investment Alliance and CASE at Duke University have partnered to create Scaling Pathways, an in-depth look at best practices and case studies for scaling impact. The series includes:
• Pivoting to Impact: Diving into the critical global lessons learned and information vital to enterprises and funders trying to scale.
• Case Studies: Telling the stories of three organizations, their scaling strategies, pivots, successes, and failures on the road to scale.
• Thematic Studies: Detailing some best practices in financing, government partnerships, talent acquisition, pathways to scale, and data.
• Scaling Snapshots: Brief narratives on the scaling journies and strategies of leading social enterprises.
WHAT IS THE INNOVATION INVESTMENT ALLIANCE?
The Innovation Investment Alliance (IIA) is a funding and learning partnership between the Skoll Foundation and USAID’s Global Development Lab, with support from Mercy Corps, that has invested almost $50 million in eight proven, transformative social enterprises to scale their impact. Together, we aim to create systems-level change across sectors and geographies and draw out lessons on scaling that are applicable to the social enterprise community and inform the ongoing conversation on how to create sustainable impact at scale.
Evidence-based resources, including toolkits, guidance, and capacity-building materials, are used by routine immunization programs to achieve critical global immunization targets. These resources can help spread information, change or improve behaviors, or build capacity based on the latest evidence and experience. Yet, practitioners have indicated that implementation of these resources can be challenging, limiting their uptake and use. It is important to identify factors that support the uptake and use of immunization-related resources to improve resource implementation and, thus, adherence to evidence-based practices.
Methods:
A targeted narrative review and synthesis and key informant interviews were conducted to identify practice-based learning, including the characteristics and factors that promote uptake and use of immunization-related resources in low- and middle-income countries and practical strategies to evaluate existing resources and promote resource use.
Results:
Fifteen characteristics or factors to consider when designing, choosing, or implementing a resource were identified through the narrative review and interviews. Characteristics of the resource associated with improved uptake and use include ease of use, value-added, effectiveness, and adaptability. Factors that may support resource implementation include training, buy-in, messaging and communication, human resources, funding, infrastructure, team culture, leadership support, data systems, political commitment, and partnerships.
Conclusion:
Toolkits and guidance play an important role in supporting the goals of routine immunization programs, but the development and dissemination of a resource are not sufficient to ensure its implementation. The findings reflect early work to identify the characteristics and factors needed to promote the uptake and use of immunization-related resources and can be considered a starting point for efforts to improve resource use and design resources to support implementation.
The SmaRT Pack project’s, hereafter the project, overall objective is to consolidate, implement, evaluate, and promote best-bet interventions at the producer level while ensuring equitable access to input supplies and services and political support. It focuses on the small ruminant value chains (SRVC) to facilitate quality products to a growing market in Ethiopia. The project’s vision is for all Ethiopians to benefit from equitable, sustainable and efficient sheep and goat value chains: animals are more productive, livestock markets work for producers, consumers and businesses, there are more affordable and healthier small ruminant products, and the livelihoods and capacities of people involved in the whole chain are improved by 2024 The core intervention of the project is the packaging of improved genetics and integrated interventions (animal health, fattening of culled animals, feeding for breeding animals) for SRVC, referred to as the SmaRT Package or SmaRT Pack. The package has been consolidated in the current target villages and implemented as an integrated package in the new target villages. The project selected three sheep and one goat value chain sites in its most recent implementation phase in the last two years. The current value chain sites, including old and new areas, are Doyogena, Bonga, Menz, and Abergele.
This report examines the project using the Light Track of ILRI's Scaling Framework.
Low- and Middle-Income countries (LMICs) is becoming an increasingly important area of interest for actors seeking to build efficient, resilient and adaptive health systems. The challenges of meeting the health targets set out in the 2030 Sustainable Development Goals are significant — even for those countries with mature and well-resourced health systems — and this is generating increased interest among many governments in exploring how health innovations might help to accelerate their progress.
International development agencies committed to supporting SDG targets have been active for many years on the supply-side of this equation, providing funding and technical assistance to innovators with a view to building a pipeline of health innovations. While the emphasis on finding solutions has surfaced some powerful and impactful innovations proven to help improve health outcomes, the ‘pipeline’ has become, in reality, more of a ‘pile-up’ with only a tiny proportion of those innovations actually successfully going to scale. Many factors appear to be influencing this process. While innovations or programs developed in the context of donor-funded projects have largely focused on scaling up through the public sector, this has been less the case for innovations generated from Grand Challenges or other independent innovation mechanisms. A large proportion of these have focused on scaling through commercial (market-driven) pathways, with support for innovators oriented towards social enterprise / for-profit models. In contrast, case studies and best practices for scaling innovations through
public sector scaling pathways remain somewhat scarce, as does support for innovators pursuing those pathways.
A key contributing factor to this is that while there are a
wide range of innovations that have been developed and tested against a well-defined problem, a large proportion of these have failed to take into account whether demand or political will for uptake of those innovations within the public sector exists. Some innovations gather dust on the shelf because their requirements for sustainable implementation at scale are significantly misaligned with the realities of resource-constrained settings. Others lack clarity around which problem they are really trying
to address, thereby confusing potential adopters within
government as to how these innovations might be most
efficiently deployed. Perhaps most significantly, the
processes by which many innovations are designed and tested have typically excluded or relegated government participation until the very final stages. They have assumed that if an innovation produces promising results at a pilot / proof of concept stage, demand for and the resources required for scale-up of that product or service among governments and others will naturally materialize (or be easily generated with minimal advocacy). In reality, this is rarely the case and the few health innovations that do go to scale in this more spontaneous manner are typically those that fulfil a very unique set of
characteristics.
This report suggests that successful scale-up of
innovations through the public sector in LMICs requires
a much more sophisticated understanding of, and
support for, the demand-side of the process. Innovators and their supporters need to find more ways to work collaboratively with potential government adopters or purchasers of innovations from the very beginning to support co-creation of solutions and smoother pathways to scale. In this way, donors, innovators and governments can co-create an environment that more effectively enables health system integration of innovations in the
long term.
While there are many reasons why scaling is not happening, there is a general consensus that a lack of systematic focus on -- and funding for -- scaling is a central factor. This is compounded by the fact that most of the projects and uses which development assistance supports remain largely determined by donors themselves i.e. is supply-driven. In this context, the Scaling Community of Practice (CoP) has proposed to do a major study of mainstreaming of scaling by international development funders (IDFs),1 hereafter just referred to as mainstreaming. Given the ambition and resources required for such a study, the CoP commissioned preliminary research on mainstreaming to inform and guide that study.
Methods: To explore these issues, a multidisciplinary two-day workshop involving experts in physical activity scale-up was convened by the University of Newcastle, Australia, and the University of Ottawa, Canada (February 2019);
Results: In this paper we discuss some of the scale-up tensions (challenges and conflicts) and paradoxes (things that are contrary to expectations) that emerged from this workshop in the context of the current literature and our own experiences in this field. We frame scale-up tensions according to epistemology, methodology, time, and partnerships; and paradoxes as ‘reach without scale’, ‘planned serendipity’ and ‘simple complexity’. We reflect on the implications of these scale-up tensions and paradoxes, providing considerations for future scale-up research and practice moving forward;
Conclusions: In this paper, we delve deeper into stakeholders’ assumptions, processes and expectations of scaling up, and challenge in what ways as stakeholders, we all contribute to desired or undesired outcomes. Through a lens of ‘tensions’ and ‘paradoxes’, we make an original contribution to the scale-up literature that might influence current perspectives of scaling-up, provide future approaches for physical activity promotion, and contribute to understanding of dynamic of research-practice partnerships.
Scaling up population health interventions is a context-orientated, dynamic and multi-stakeholder process; understanding its influences is essential to enhance future scaling efforts. Using physical activity and nutrition interventions in Australia as case examples, the aim of this paper is to identify core influences involved in scaling up physical activity and nutrition interventions, and how these may differ by context and stakeholder.
Methods
A qualitative study involving semi-structured telephone interviews with individuals representing academic, government and non-government organizations with involvement in scaling up state and national physical activity and nutrition interventions. Interview questions were derived from the WHO report “20 Questions for Developing a Scaling up Case Study”, and mapped against four key principles and five core areas in the WHO ExpandNet framework for scaling up: (1) The innovation; (2) User organization; (3) Environment; (4) Resource team and; (5) Scale up strategy. Data were analyzed thematically.
Results
Nineteen interviews were conducted (government = 3; non-government = 5; and academic = 11 sectors) involving eight scaled up interventions, targeting nutrition (n = 2), physical activity (n = 1) or a combination (n = 5). Most themes aligned to the “Environment”, including: (i) political (e.g., personal agendas); (ii) social (e.g., lack of urgency); and (iii) sector/workforce (e.g., scale up accountability) factors. Themes relating to “Scale up strategy” (e.g., flexibility and evaluation transparency) were next most commonly occurring. Whilst themes were broadly consistent across participants, government participants had a more policy-oriented perspective on the scale up process. Academics discussed a tension between the generation and use of evidence, and the influence of political climates/interest on scale up decisions.
Conclusion
Attributes of the “Environment” and “Scale up strategy” consistently featured as major influences on successful outcomes, while the role of evidence differed greatly between participant groups. A multisector scale up strategy for future interventions may enable the complexities of environmental and political contexts to be incorporated into scale up planning.
This was innovation. And yet, despite how many more behavioral insights trials have been run by intrapreneurs in this organization—often supported by the in-house innovation team—this kind of behavioral insights is still considered “innovative.” The approach has not (yet) been brought to how business is done on a regular basis.
By contrast, in the decade since intrapreneurs in the Western Cape Government in South Africa first initiated behavioral insights trials, it has come to occupy a secure place in the government’s toolkit. Public servants know when it’s appropriate to take a behavioral approach, and they are supported with in-house expertise and guidance. In a distinct and dramatic sense, behavioral insights have been adopted.
The adoption of innovation means an innovation has ceased to be “innovative.” It means that a method, technology, or approach to a problem has moved from the experimental edges of an organization to the core of its work: no longer a novelty, but something normal and institutionalized.
However, the concept of adoption is rarely discussed, and the experience and know-how to bring it about is even less common. While an increasing evidence base has been developed on adopting digital systems in development and public sector organizations, as well as literature on organizational reform, little has been published on strategically moving approaches and technologies out of the innovation space to the mainstream of how organizations work. The most relevant insights come from institutionalizing behavioral insights in governments, mainly in public sector entities in the global north. This gap makes it all the more important to surface the challenges, opportunities, and factors that enable adoption, as well as the barriers and roadblocks that impede it.
This systematic literature review explores scaling within the context of AR4D, with a particular focus on the role of social capital. Using bibliometric and factor analysis methods, we identified the intellectual structure in the field of scaling, revealing the knowledge domains and disciplines that have determined their emergence and growth as a scientific discipline. Then, we analyzed the role of social capital in the scaling literature.
Our results showed that the field of scaling is composed by four distinct literature clusters: the innovation and adoption of agricultural technology, the economics of technology adoption, sustainability in agricultural innovations, and the emergence of scaling as a research field. Disciplines such as sustainable agriculture, systemic thinking, technological transitions, and technology adoption have contributed to the development of the field. The results indicate that the explicit consideration of social capital in the scaling literature within AR4D is limited despite the importance of relationships, trust, and reciprocity values in the process of scaling.
This study highlights the continuous growth and multidisciplinary nature of scaling as a research field in AR4D, reflecting its complexity. International agricultural research centers and universities from developed countries have significantly advanced this field, also underlying the importance of locally rooted, and participatory research. Future research on the creation, development, and strengthening of social capital in scaling processes can contribute foster intentional and responsible scaling of AR4D innovations.
• Tool 1: Define the intervention package 1
• Tool 2: Scalability Checklist 2
• Tool 3: Assess Implementer Capacity
• Tool 4: Assess Scale up Environment 1
• Tool 5: Identify Key Stakeholders and Describe Scale up Management Team 1
• Tool 6: Roles and Responsibilities for Leaders and Managers
• Tool 7: Plan Scale-up Strategies for Institutionalization and Service Expansion 1
• Tool 8: Developing a Vision for Reaching Sustainable Impact at Scale 1
These growing unmet needs, coupled with the presence of economies of scale that affect most nonprofits, mean that achieving social impact at scale has never been more important. Even so, the sector is rife with examples of nonprofits that fail in their pursuit of that goal. Many organizations remain small, despite efforts to expand. And many organizations that grow in size fail to grow in impact. This dynamic often occurs because organizations are too quick to move into scaling mode. They regard their right to pursue impact at scale as a given. Yet organizations that succeed in expanding their impact almost always begin that process by establishing that they are scale-ready and, indeed, scale-worthy. In short, they “earn the right” to scale, and they do so by excelling at all of the essential elements of nonprofit performance.
Earning the right to scale, in our view, takes place as the culmination of a deep, long-term commitment to strategic leadership. That’s our term for a model that brings together seven essential elements. Before an organization begins to scale up its operation and deepen its impact, it must have all of those elements in place. It must develop a clear and well-focused mission, and it must hone its strategy, and it must practice rigorous impact evaluation, and it must display the kind of insight and courage that foster real change. Equally important, it must manage its talent to build a high-performance organization, and it must fund its efforts adequately, and it must ensure effective board governance. In a previous article, we focused on three of these elements (board governance, funding, and impact evaluation), but to truly succeed at scaling, organizations need to tackle all seven elements in a comprehensive way.
A survey we conducted to determine how well nonprofits are faring in these seven areas drew responses from more than 3,000 people in the nonprofit sector. This survey, which we released in 2017, provides empirical data on the extent to which nonprofit organizations today are (or are not) scale-ready. More than 80 percent of respondents indicated that their organization struggles to perform at a high level in one or more of the seven elements of strategic leadership. Most organizations, in other words, fall short of having earned the right to scale up their work.
To maximise the impact of public health research, research interventions found to be effective in improving health need to be scaled up and delivered on a population-wide basis. Theoretical frameworks and approaches are useful for describing and understanding how effective interventions are scaled up from small trials into broader policy and practice and can be used as a tool to facilitate effective scale-up. The purpose of this literature review was to synthesise evidence on scaling up public health interventions into population-wide policy and practice, with a focus on the defining and describing frameworks, processes and methods of scaling up public health initiatives.
Methods
The review involved keyword searches of electronic databases including MEDLINE, CINAHL, PsycINFO, EBM Reviews and Google Scholar between August and December 2013. Keywords included ‘scaling up’ and ‘scalability’, while the search terms ‘intervention research’, ‘translational research’, ‘research dissemination’, ‘health promotion’ and ‘public health’ were used to focus the search on public health approaches. Studies included in the review were published in English from January 1990 to December 2013 and described processes, theories or frameworks associated with scaling up public health and health promotion interventions.
Results
There is a growing body of literature describing frameworks for scaling health interventions, with the review identifying eight frameworks, the majority of which have an explicit focus on scaling up health action in low and middle income country contexts. Key success factors for scaling up included the importance of establishing monitoring and evaluation systems, costing and economic modelling of intervention approaches, active engagement of a range of implementers and the target community, tailoring the scaled-up approach to the local context, the use of participatory approaches, the systematic use of evidence, infrastructure to support implementation, strong leadership and champions, political will, well defined scale-up strategy and strong advocacy.
Conclusions
Effective scaling up requires the systematic use of evidence, and it is essential that data from implementation monitoring is linked to decision making throughout the scaling up process. Conceptual frameworks can assist both policy makers and researchers to determine the type of research that is most useful at different stages of scaling up processes.
Our pilot study, which included 1,900 households, was evaluated through a randomized controlled trial (RCT) in 2008, and it seemed to be successful. Small subsidies of US$11.50 — enough to pay for the round-trip bus fare plus a few days of food — boosted the percentage of agricultural workers heading to cities during the lean season from 36% to 58%. The families of the migrants consumed more than 600 extra calories per person each day — essentially, they were eating three meals instead of two. Moreover, about half of those who moved chose to migrate again without subsidy during subsequent lean seasons, and many found work with the same employer that they had connected with in 2008.
We scaled up the programme in stages, each time expanding the observations we made: these included risk of divorce, changes in prices of goods and the costs of family separation. These data helped us to capture the unintended consequences of more migrants leaving their villages and entering urban labour markets. Results continued to look promising, and a large microcredit organization in Bangladesh received philanthropic support to offer seasonal-migration loans to hundreds of thousands of households. But the outcome was disappointing — subsidies mainly reached those who would have migrated anyway, and the programme was promptly discontinued. Although this was disheartening, I remain proud of collecting that decision-aiding information: it prevented waste and meant that the limited money for anti-poverty programmes was better spent.
When programmes enter a ‘scaling stage’, the focus often immediately shifts to solving the practical issues of broader implementation of the programme (such as how to teach government staff about an innovation, distribute subsidies to tens of thousands of people, instead of hundreds, or integrate a programme across government systems). All that work, although essential, overlooks the crucial question of whether exciting pilot results still hold. Many — if not most — development programmes encounter uncertainties and complexities that emerge only at scale. These are rarely observed — and therefore cannot be analysed — during the initial pilots. Simply repeating interventions on the same scale at multiple locales is not enough.
Population health interventions (PHIs) have the potential to improve the health of large populations by systematically addressing underlying conditions of poor health outcomes (i.e., social determinants of health) and reducing health inequities. Scaling-up may be one means of enhancing the impact of effective PHIs. However, not all scale-up attempts have been successful. In an attempt to help guide the process of successful scale-up of a PHI, we look to the organizational readiness for change theory for a new perspective on how we may better understand the scale-up pathway. Using the change theory, our goal was to develop the foundations of an evidence-based, theory-informed framework for a PHI, through a critical examination of various PHI scale-up experiences documented in the literature.
Methods: We conducted a multi-step, critical interpretive synthesis (CIS) to gather and examine insights from scale-up experiences detailed in peer-reviewed and grey literatures, with a focus on PHIs from a variety of global settings. The CIS included iterative cycles of systematic searching, sampling, data extraction, critiquing, interpreting, coding, reflecting, and synthesizing. Theories relevant to innovations, complexity, and organizational readiness guided our analysis and synthesis.
Results: We retained and examined twenty different PHI scale-up experiences, which were extracted from 77 documents (47 peer-reviewed, 30 grey literature) published between 1995 and 2013. Overall, we identified three phases (i.e., Groundwork, Implementing Scale-up, and Sustaining Scale-up), 11 actions, and four key components (i.e., PHI, context, capacity, stakeholders) pertinent to the scale-up process. Our guiding theories provided explanatory power to various aspects of the scale-up process and to scale-up success, and an alternative perspective to the assessment of scale-up readiness for a PHI.
Conclusion: Our synthesis provided the foundations of the Scale-up Readiness Assessment Framework. Our theoretically-informed and rigorous synthesis methodology permitted identification of disparate processes involved in the successful scale-up of a PHI. Our findings complement the guidance and resources currently available, and offer an added perspective to assessing scale-up readiness for a PHI.
Keywords: Critical interpretive synthesis; Framework; Population health intervention; Readiness; Scale-up.
The scale-up and sustainability of social innovations for health have received increased interest in global health research in recent years; however, these ambiguous concepts are poorly defined and insufficiently theorised and studied. Researchers, policymakers, and practitioners lack conceptual clarity and integrated frameworks for the scale-up and sustainability of global health innovations. Often, the frameworks developed are conceived in a linear and deterministic or consequentialist vision of the diffusion of innovations. This approach limits the consideration of complexity in scaling up and sustaining innovations.
Objective
By using a systems theory lens and conducting a narrative review, this manuscript aims to produce an evidence-based integrative conceptual framework for the scale-up and sustainability of global health innovations.
Method
We conducted a hermeneutic narrative review to synthetise different definitions of scale-up and sustainability to model an integrative definition of these concepts for global health. We have summarised the literature on the determinants that influence the conditions for innovation success or failure while noting the interconnections between internal and external innovation environments.
Results
The internal innovation environment includes innovation characteristics (effectiveness and testability, monitoring and evaluation systems, simplification processes, resource requirements) and organisational characteristics (leadership and governance, organisational change, and organisational viability). The external innovation environment refers to receptive and transformative environments; the values, cultures, norms, and practices of individuals, communities, organisations, and systems; and other contextual characteristics relevant to innovation development.
Conclusion
From these syntheses, we proposed an interconnected framework for action to better guide innovation researchers, practitioners, and policymakers in incorporating complexity and systemic interactions between internal and external innovation environments in global health.
The completion of an implementation research project typically signals the end of research. In contrast, the Ghana Health Service has embraced a continuous process of evidence-based programming, wherein each research episode is followed by action and a new program of research that monitors and guides the utilization of lessons learned. This paper reviews the objectives and design of the most recent phase in this process, known as a National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+).
Methods
A mixed method evaluation strategy has been launched involving: i) baseline and endline randomized sample surveys with 247 clusters dispersed in 14 districts of the Northern and Volta Regions to assess the difference in difference effect of stepped wedge differential cluster exposure to CHPS+ activities on childhood survival, ii) a monitoring system to assess the association of changes in service system readiness with CHPS+ interventions, and iii) a program of qualitative systems appraisal to gauge stakeholder perceptions of systems problems, reactions to interventions, and perceptions of change. Integrated survey and monitoring data will permit multi-level longitudinal models of impact; longitudinal QSA data will provide data on the implementation process.
Discussion
A process of exchanges, team interaction, and catalytic financing has accelerated the expansion of community-based primary health care in Ghana’s Upper East Region (UER). Using two Northern and two Volta Region districts, the UER systems learning concept will be transferred to counterpart districts where a program of team-based peer training will be instituted. A mixed method research system will be used to assess the impact of this transfer of innovation in collaboration with national and regional program management. This arrangement will generate embedded science that optimizes prospects that results will contribute to national CHPS reform policies and action.
Methods: This qualitative study was undertaken between August 2020 and July 2021. 43 semi-structured interviews were conducted with project investigators, implementers and policymakers, across 19 diverse scale-up projects, being implemented in 20 countries. The transcripts were inductively, open-coded using thematic analysis. Generated themes were mapped systematically to four out of five domain categorisations of the Consolidated Framework for Implementation Research (CFIR); the innovation domain fell outside the scope of this study.
Results: Highlighted findings using CFIR are: (i) outer setting: influence of politics, lack of coordination between government departments and differing agendas towards NCDs hindered implementation while reliable and trustworthy government connections proved useful; (ii) inner setting: commitment of resources for implementation was a challenge while research capacity, work culture and trustworthy networks facilitated implementation; (iii) individuals: high-level stakeholder support and leadership was essential; (iv) process: extensive time and efforts required for stakeholder engagement towards local contextualisation was challenging, while collaborating, joint reflection, effective communication and adaptation facilitated. COVID-19 provided both challenges and opportunities and these varied depending on the intervention characteristics and study objectives.
Conclusion: Researchers supporting the scale-up of complex interventions targeting NCDs need to leverage on existing trusting relationships and foster equitable stakeholder partnerships through research. Interpersonal skills and good communication are essential complements to research expertise and must be considered during capacity building.
Kevin Starr is CEO of the Mulago Foundation, and has taught hundreds of social entrepreneurs and other leaders how to approach impact at scale, and there’s nothing he likes better. Mark Reading is Head of Foundation at Atlassian, where he is the bridge between the Australian technology success-story that is Atlassian, and the charities they choose to support through their Pledge-1% model.
To evaluate the effectiveness of quality improvement collaboratives in improving the quality of care. Data sources Relevant studies through Medline, Embase, PsycINFO, CINAHL, and Cochrane databases. Study selection Two reviewers independently extracted data on topics, participants, setting, study design, and outcomes. Data synthesis Of 1104 articles identified, 72 were included in the study. Twelve reports representing nine studies (including two randomised controlled trials) used a controlled design to measure the effects of the quality improvement collaborative intervention on care processes or outcomes of care. Systematic review of these nine studies showed moderate positive results. Seven studies (including one randomised controlled trial) reported an effect on some of the selected outcome measures. Two studies (including one randomised controlled trial) did not show any significant effect.
Conclusions
The evidence underlying quality improvement collaboratives is positive but limited and the effects cannot be predicted with great certainty. Considering that quality improvement collaboratives seem to play a key part in current strategies focused on accelerating improvement, but may have only modest effects on outcomes at best, further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives.
We’ve spent 10 years helping mission-driven organizations across the world to scale their impact. What you’re reading about now – the Journey to Impact report – is part of our commitment to sharing knowledge with the social sector.
Whether you’re a mission-driven organization looking to scale your impact, or a funder interested in supporting their grantees to more effectively achieve the impact they seek, the report will provide you with lots of direct, applicable insight.
Call it exponential, geometric, what have you—the point is that the curve steepens, and impact (I) accelerates dramatically over time (T). We know it takes a while; we know that “the hockey stick” is bullshit, but in the end we need to see something that looks like that curve.
Since we need to talk about scale—and design for it—with lots of organizations doing lots of different things, we wanted to find a simpler, more usable way to talk and think about it. Over time, we realized that if you want to get to real scale, two questions really matter: 1) Who’s the doer, and 2) who’s the payer?
There is widespread agreement on the need for scaling up in the health sector to achieve the Millennium Development Goals (MDGs). But many countries are not on track to reach the MDG targets. The dominant approach used by global health initiatives promotes uniform interventions and targets, assuming that specific technical interventions tested in one country can be replicated across countries to rapidly expand coverage. Yet countries scale up health services and progress against the MDGs at very different rates. Global health initiatives need to take advantage of what has been learned about scaling up.
Methods:
A systematic literature review was conducted to identify conceptual models for scaling up health in developing countries, with the articles assessed according to the practical concerns of how to scale up, including the planning, monitoring and implementation approaches.
Results:
We identified six conceptual models for scaling up in health based on experience with expanding pilot projects and diffusion of innovations. They place importance on paying attention to enhancing organizational, functional, and political capabilities through experimentation and adaptation of strategies in addition to increasing the coverage and range of health services. These scaling up approaches focus on fostering sustainable institutions and the constructive engagement between end users and the provider and financing organizations.
Conclusions:
The current approaches to scaling up health services to reach the MDGs are overly simplistic and not working adequately. Rather than relying on blueprint planning and raising funds, an approach characteristic of current global health efforts, experience with alternative models suggests that more promising pathways involve “learning by doing” in ways that engage key stakeholders, uses data to address constraints, and incorporates results from pilot projects. Such approaches should be applied to current strategies to achieve the MDGs.
Keywords NGOs civil society Asia India advocacy scaling up
Translating research evidence into practice is challenging and, to date, there are relatively few public health interventions that have been effectively and cost-effectively implemented and delivered at scale. Theories, models and frameworks (herein termed ‘frameworks’) have been used in implementation science to describe, guide and explain implementation and scale-up. While economic constructs have been reported as both barriers and facilitators to effective implementation and scale-up of public health interventions, there is currently no published review of how economic constructs are considered within commonly used implementation and scale-up frameworks. This paper aimed to narratively review the economic constructs incorporated in commonly used implementation and scale-up frameworks.
Methods
Frameworks for inclusion in the narrative review were identified from the literature and thematic content analysis was undertaken using a recursive deductive approach. Emergent key themes and sub-themes were identified and results were summarised narratively within each theme.
Results
Twenty-six framework publications were included in our analysis, with wide variation between frameworks in the scope and level of detail of the economic constructs included. Four key themes emerged from the data – ‘resources’, ‘benefit’, ‘cost’ and ‘funding’. Only five frameworks incorporated all four identified key themes. Overarching lenses from which to consider key themes included ‘stakeholder perspectives’, ‘stage in the research translation process’ and ‘context’. ‘Resources’ were most frequently considered in relation to the sub-themes of ‘types of resources’ (e.g. labour, time or infrastructure) and ‘availability’ of resources, and the opportunity for ‘economies of scale’. The ‘relative advantage of interventions’ emerged as an interconnecting sub-theme between ‘cost’ and ‘benefit’. ‘Funding’ was most often considered in relation to ‘funding sources’, ‘availability’, ‘sustainability’ or ‘contextual impact’. The concept of ‘opportunity cost’ was considered in relatively few frameworks, despite being fundamental to economic theory.
Conclusions
Implementation and scale-up frameworks provide a conceptual map to inform the effective and cost-effective implementation of public health interventions delivered at scale. Despite evidence of an emerging focus on the economic considerations of implementation and scale-up within some commonly used frameworks, our findings suggest that there is significant scope for further exploration of the economic constructs related to implementation and scale-up. Keywords: Implementation, scale-up, theories, models, frameworks, economic
Keywords DELIVERY OF HEALTH CARE DIFFUSION OF INNOVATION HEALTH PROMOTION PROGRAM DEVELOPMENT PROGRAM EVALUATION REGIONAL HEALTH PLANNING
Most low and middle income countries (LMICs) are currently not on track to reach the health-related Millennium Development Goals (MDGs). One way to accelerate progress would be through the large-scale implementation of evidence-based health tools and interventions. This study aimed to: (a) explore the barriers that have impeded such scale-up in LMICs, and (b) lay out an “implementation research agenda”—a series of key research questions that need to be addressed in order to help overcome such barriers.
Methods:
Interviews were conducted with fourteen key informants, all of whom are academic leaders in the field of implementation science, who were purposively selected for their expertise in scaling up in LMICs. Interviews were transcribed by hand and manually coded to look for emerging themes related to the two study aims. Barriers to scaling up, and unanswered research questions, were organized into six categories, representing different components of the scaling up process: attributes of the intervention; attributes of the implementers; scale-up approach; attributes of the adopting community; socio-political, fiscal, and cultural context; and research context.
Results:
Factors impeding the success of scale-up that emerged from the key informant interviews, and which are areas for future investigation, include: complexity of the intervention and lack of technical consensus; limited human resource, leadership, management, and health systems capacity; poor application of proven diffusion techniques; lack of engagement of local implementers and of the adopting community; and inadequate integration of research into scale-up efforts.
Conclusions:
Key steps in expanding the evidence base on implementation in LMICs include studying how to: simplify interventions; train “scale-up leaders” and health workers dedicated to scale-up; reach and engage communities; match the best delivery strategy to the specific health problem and context; and raise the low profile of implementation science.
Scale-up, scalability, evaluation
Tools to Support Scale Up
• Scaling of innovations requires a conducive policy, financial, social and busines environment and if these are not present, it needs supporting innovations to improve those conditions.
• Scaling of innovations should be a means to an end. More is not always better; agriculture is the largest user and polluter of water, and one of the biggest threats to biodiversity, for example.
• Reaching high numbers of adopters during projects is important but how they are reached is more important. After all, we want impact at scale to sustain and grow beyond the project boundaries (time and space). Meaningful scaling is about designing for sustainable and responsible change at scale from the beginning, nurturing local ownership and leadership, and learning and adjusting along the journey. Scaling of innovations is one the key pieces of the puzzle to achieve impact at scale, along with changing in conditions that hold problems in place (root causes) and supporting innovations that contribute to an enabling environment. Why the Scaling Scan? The multi-dimensional nature of scaling an innovation has discouraged scaling practitioners to engage in meaningful scaling, count adopters at the end of the project and assume others will continue scaling when project support cedes. The Scaling Scan provides a user-friendly tool to explore what is required to scale an innovation in a particular context, the implications this has for project management and collaborations and the potential trade-offs on the environment as well as social dynamics. At the core of the Scaling Scan are ten scaling ingredients that constitute the enabling environment around an innovation, and largely influence whether a scaling ambition can be realistically achieved. The Scaling Scan can be used to:
• facilitate discussion and develop capacities on scaling of a range of stakeholders;
• help formulate a realistic, context-specific and responsible scaling ambition for a selected innovation; • rapidly scan for bottlenecks and opportunities of a scaling initiative and generate immediate information to adjust strategies or identify needs for new collaborations;
• check whether project proposals, implementation plans, and evaluations misses important scaling elements. Who is the Scaling Scan for? The Scaling Scan is designed for anyone involved in pro-poor and sustainable development programs looking to scale impact. Project coordinators, managers and teams who manage project resources and priorities will be those most able to take advantage of the tool. It is specifically designed to develop capacity of nonscaling experts to recognize, and make sense of, scaling in their context. We highly recommend involving a diverse set of stakeholders for richer and more deliberate choices on what needs to be addressed and done to achieve the scaling ambition. Furthermore, the Scaling Scan can be applied:
• Within a range of sectors, despite being based on experience from the agriculture and the water sector
• By individuals as well as (project) teams
• By individual organizations and partnerships
Implementation Science
Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up.
Methods
We draw upon three IR studies conducted by Future Health Systems (FHS) in Afghanistan, Bangladesh and Uganda. We reviewed project documents from the period 2011–2016 to identify information related to the dimensions of scaling up. Further, for each country, we developed rich descriptions of how the research teams approached scaling up, and how IR contributed to scale-up. The rich descriptions were checked by FHS research teams. We identified common patterns and differences across the three cases.
Results
The three cases planned quite different innovations/interventions and had very different types of scale-up strategies. In all three cases, the research teams had extensive prior experience within the study communities, and little explicit attention was paid to contextual factors. All three cases involved complex interactions between the research teams and other stakeholders, among stakeholders, and between stakeholders and the intervention. The IR planned by the research teams focussed primarily on feasibility and effectiveness, but in practice, the research teams also had critical insights into other factors such as sustainability, acceptability, cost-effectiveness and appropriateness. Stakeholder analyses and other project management tools further complemented IR.
Conclusions
IR can provide significant insights into how best to scale-up a particular intervention. To take advantage of insights from IR, scale-up strategies require flexibility and IR must also be sufficiently flexible to respond to new emerging questions. While commonly used conceptual frameworks for scale-up clearly delineate actors, such as implementers, target communities and the support team, in our experience, IR blurred the links between these groups.
▪ Better documentation of the context in which interventions are implemented in order to better understand implementation barriers and facilitators as well as to inform replication of interventions to different settings and their scale up. This calls for careful documentation of examples of IS in FP/ RH shared through peer-reviewed literature and other avenues in order to make them widely available and accessible.
▪ Clear examples of what is successful implementation science and how it is measured (i.e., feasibility, sustainability, scale up). Engaging donors and funders in the development and refinement of these measures may help to identify new investment opportunities in implementation science.
▪ Development of the capacity building agenda for IS at different levels (e.g. local researchers, national policymakers, global and national implementers, advocates) will strengthen the influence of implementation science.
▪ Finding opportunities to strengthen partnership between the research and advocacy communities to generate additional avenues to ensure evidence utilization.
▪ Determining how best we can use IS to get better costing data so that we can publicize “best buys” within FP/RH.
We describe the use of a conceptual framework and implementation protocol to prepare effective health services interventions for implementation in community-based (i.e., non-academic-affiliated) settings.
Methods
The framework is based on the experiences of the U.S. Centers for Disease Control and Prevention (CDC) Replicating Effective Programs (REP) project, which has been at the forefront of developing systematic and effective strategies to prepare HIV interventions for dissemination. This article describes the REP framework, and how it can be applied to implement clinical and health services interventions in community-based organizations.
Results
REP consists of four phases: pre-conditions (e.g., identifying need, target population, and suitable intervention), pre-implementation (e.g., intervention packaging and community input), implementation (e.g., package dissemination, training, technical assistance, and evaluation), and maintenance and evolution (e.g., preparing the intervention for sustainability). Key components of REP, including intervention packaging, training, technical assistance, and fidelity assessment are crucial to the implementation of effective interventions in health care.
Conclusion
REP is a well-suited framework for implementing health care interventions, as it specifies steps needed to maximize fidelity while allowing opportunities for flexibility (i.e., local customizing) to maximize transferability. Strategies that foster the sustainability of REP as a tool to implement effective health care interventions need to be developed and tested.
There is a growing interest in scaling effective health innovations to promote equitable access to high-quality health services worldwide. However, multiple challenges persist in scaling innovations. In this study, we aim to summarize the scaling evidence in the health and social care literature and identify current knowledge gaps.
Methods
We will conduct a living umbrella review according to the Joanna Briggs Institute Reviewers’ Manual. We will consider all knowledge syntheses addressing scaling in health or social care (e.g., any setting, any clinical area) and conducted in a systematic way. We will search the following electronic databases: MEDLINE (Ovid), Embase, PsychINFO (Ovid), CINAHL (EBSCO), Web of Science, The Cochrane Library, Sociological Abstract (Proquest), Academic Search Premier (EBSCO), and Proquest Dissertations & Theses Global, from inception. Furthermore, we will conduct searches of the grey literature. No restriction regarding date or language will be applied. Each phase of the review will be processed by two independent reviewers. We will develop a data extraction form on Covidence. We will assess the methodological quality of the included reviews using AMSTAR2 and the risk of bias using ROBIS. Results will be presented in tabular form and accompanied by a narrative synthesis covering the traditional themes of scaling science that emerge from the analysis, such as coverage, range, and sustainability, as well as themes less covered in the literature, including reporting guidance, models, tools, barriers, and/or facilitators to scaling innovations, evidence regarding application in high-income or low-income countries, and end-user engagement. We will disseminate the findings via publications and through relevant networks.
Discussion
The findings of the umbrella review will facilitate access to scaling evidence in the literature and help strengthen the science of scaling for researchers, policy makers, and program managers. Finally, this work will highlight important knowledge gaps and help prioritize future research questions.
Despite irrefutable health benefits of physical activity, older adults remain among the least active Canadians. To achieve population health, physical activity interventions that proved effective in controlled research settings must be delivered at scale to reach broader populations of older adults across multiple settings. Formative evaluations are essential, as they identify barriers and enablers to implementation across levels of stakeholder groups and settings. Thus, we conducted a formative evaluation of a choice- and evidence-based physical activity intervention (Men on the Move) designed for scalability.
Methods
We adopted key elements of two implementation frameworks that place characteristics of the innovation, prevention delivery system, prevention support system, and prevention synthesis and translation system at the core of implementation success. Guided by the Interactive Systems Framework for Dissemination and Implementation, data were collected from delivery partners, including 1 leader from a key provincial recreation organization, 6 recreation directors/coordinators and 3 activity coaches, and 14 participants (older men). This research team participated in prevention support and prevention synthesis and translation systems. Two trained interviewers conducted telephone interviews with delivery partners, and five trained interviewers and a notetaker conducted in-person interviews with participants.
Results
Five themes emerged from analyses of delivery partner interviews: support, activity coaches, intervention delivery, Men on the Move continuation, and the absence of men. Two themes emerged from our analyses of participant data: monitoring and connectedness.
Conclusion
Lessons learned from this formative evaluation will guide the adaptation of the intervention to context and population for scale-up across British Columbia, Canada. In so doing, we aim to bridge the know–do–scale-up gap, which is imperative as we seek to improve older adult health at the population level.
Promising health interventions tested in pilot studies will only achieve population-wide impact if they are implemented at scale across communities and health systems. Scaling up effective health interventions is vital as not doing so denies the community the most effective services and programmes. However, there remains a paucity of practical tools to assess the suitability of health interventions for scale-up. The Intervention Scalability Assessment Tool (ISAT) was developed to support policy-makers and practitioners to make systematic assessments of the suitability of health interventions for scale-up.
Methods
The ISAT was developed over three stages; the first stage involved a literature review to identify similar tools and frameworks that could be used to guide scalability assessments, and expert input to develop draft ISAT content. In the second stage, the draft ISAT tool was tested with end users. The third stage involved revising and re-testing the ISAT with end users to further refine the language and structure of the final ISAT.
Results
A variety of information and sources of evidence should be used to complete the ISAT. The ISAT consists of three parts. Part A: ‘setting the scene’ requires consideration of the context in which the intervention is being considered for scale-up and consists of five domains, as follows: (1) the problem; (2) the intervention; (3) strategic/political context; (4) evidence of effectiveness; and (5) intervention costs and benefits. Part B asks users to assess the potential implementation and scale-up requirements within five domains, namely (1) fidelity and adaptation; (2) reach and acceptability; (3) delivery setting and workforce; (4) implementation infrastructure; and (5) sustainability. Part C generates a graphical representation of the strengths and weaknesses of the readiness of the proposed intervention for scale-up. Users are also prompted for a recommendation as to whether the intervention (1) is recommended for scale-up, (2) is promising but needs further information before scaling up, or (3) does not yet merit scale-up.
Conclusion
The ISAT fills an important gap in applied scalability assessment and can become a critical decision support tool for policy-makers and practitioners when selecting health interventions for scale-up. Although the ISAT is designed to be a health policy and practitioner tool, it can also be used by researchers in the design of research to fill important evidence gaps.
Although significant advances have been made in implementation science, comparatively less attention has been paid to broader scale-up and spread of effective health programs at the regional, national, or international level. To address this gap in research, practice and policy attention, representatives from key stakeholder groups launched an initiative to identify gaps and stimulate additional interest and activity in scale-up and spread of effective health programs. We describe the background and motivation for this initiative and the content, process, and outcomes of two main phases comprising the core of the initiative: a state-of-the-art conference to develop recommendations for advancing scale-up and spread and a follow-up activity to operationalize and prioritize the recommendations. The conference was held in Washington, D.C. during July 2010 and attended by 100 representatives from research, practice, policy, public health, healthcare, and international health communities; the follow-up activity was conducted remotely the following year.
Discussion
Conference attendees identified and prioritized five recommendations (and corresponding sub-recommendations) for advancing scale-up and spread in health: increase awareness, facilitate information exchange, develop new methods, apply new approaches for evaluation, and expand capacity. In the follow-up activity, ‘develop new methods’ was rated as most important recommendation; expanding capacity was rated as least important, although differences were relatively minor.
Summary
Based on the results of these efforts, we discuss priority activities that are needed to advance research, practice and policy to accelerate the scale-up and spread of effective health programs.
Efforts to scale up evidence-based health care interventions are seen as a key strategy to address complex health system challenges. However, scale-up efforts have shown significant variability. We address the gap between scale-up theory and practice by exploring the socio-cultural factors at play in the evaluation and scale-up of three interventions within the clinical field.
Methods:
A qualitative multiple case study was conducted to characterize the evaluation and scale-up efforts of three interventions. We interviewed 18 participants, including clinicians and researchers across the three cases. Using Pierre Bourdieu\'s concepts of field and capital as a theoretical lens, we conducted a thematic analysis of the data.
Results:
Despite the espoused goals of ensuring that health service interventions are always based on high-quality evidence within the clinical field, this study demonstrates that the outcomes of the evaluations are not the only factor in the decision to engage in scale-up efforts. Important socio-cultural factors also come into play. Bourdieu uses the term capital to refer to the resources that agents compete for and with their acquisition, accumulate power and/or social standing. The type of evidence valued in the clinical field and the ability to leverage capital in demonstrating that value are also important factors.
Conclusions:
Determining if an intervention is effective and should be scaled up is more complex in practice than described in the literature. Efforts are needed to explicitly include the role of social processes in the current frameworks guiding scaling-up efforts. Keywords: capital; evaluation of complex interventions; field; pilot projects; scale up.
Although the Poverty Reduction Strategy (PRS) approach was introduced just over four years ago, it is now seen as the country-level operational framework for progress towards the MDGs. Although implementation experience has varied with regard to process and content— both across countries as well as within individual countries’ strategies—a key contribution of the PRS approach has been to focus attention on country-specific constraints to development. In many low-income countries the PRS initiative has also resulted in a sharper focus on poverty reduction, a more open participatory process and greater attention to monitoring poverty-related outcomes. Over the past year (through end-June 2004), ten more countries have finalized full PRSPs, bringing to 42 the number of countries implementing PRSs. Twenty-three countries now have completed one or more annual progress reports (APR).
ISSUES IN IMPLEMENTATION
The main findings of this progress report are twofold. First, countries have made good progress in addressing the more straightforward challenges inherent in the approach. For example, poverty analysis is relatively good, strategies recognize the importance of growth and macroeconomic stability, indicators lists are being rationalized, and sectoral coverage is broadening. Second, the challenges that remain are technically difficult and institutionally complex. For example, the analysis of the sources of growth and its distributional impact remains relatively weak and countries have also experienced difficulties in marrying their aspirations for the future with the resource and capacity constraints of the present in the context of their PRSs. To better realize the potential of the PRS approach, sustained efforts on the part of countries and their development partners are, therefore, needed to: (i) reinforce the PRS as a country-driven approach; (ii) enhance the analysis that underpins a PRS; (iii) strengthen the institutional capacity for successful implementation; and (iv) enhance aid effectiveness. Given the scope of these challenges, expectations need to be ambitious yet realistic, while capacity building and analytical support must be appropriately prioritized and sequenced at the country level.
Research Utilization
To understand how knowledge is used to inform policy on Health Equity Funds (HEFs) in Cambodia; and to draw lessons for translating knowledge into health policies that promote equity.
Methods:
We used a knowledge translation framework to analyse the HEF policy process between 2000 and 2008. The analysis was based on data from document analysis, key informant interviews and authors' observations.
Results:
The HEF policy-making process in Cambodia was both innovative and incremental. Insights from pilot projects were gradually translated into national health policy. The uptake of HEF in health policy was determined by three important factors: a policy context conducive to the creation, dissemination and adoption of lessons gained in HEF pilots; the credibility and timeliness of HEF knowledge generated from pilot projects; and strong commitment, relationships and networks among actors.
Conclusions:
Knowledge locally generated through pilot projects is crucial for innovative health policy. It can help adapt blueprints and best practices to a local context and creates ownership. While international organisations and donors can take a leading role in innovative interventions in low-income countries, the involvement of government policy makers is necessary for their scaling-up.
Adaptation, Adaptive Management, Complexity and Fidelity
Adaptations are often made to evidence-based practices (EBPs) by systems, organizations, and/or service providers in the implementation process. The degree to which core elements of an EBP can be maintained while allowing for local adaptation is unclear. In addition, adaptations may also be needed at the system, policy, or organizational levels to facilitate EBP implementation and sustainment. This paper describes a study of the feasibility and acceptability of an implementation approach, the Dynamic Adaptation Process (DAP), designed to allow for EBP adaptation and system and organizational adaptations in a planned and considered, rather than ad hoc, way. The DAP involves identifying core elements and adaptable characteristics of an EBP, then supporting implementation with specific training on allowable adaptations to the model, fidelity monitoring and support, and identifying the need for and solutions to system and organizational adaptations. In addition, this study addresses a secondary concern, that of improving EBP model fidelity assessment and feedback in real-world settings.
Methods
This project examines the feasibility, acceptability, and utility of the DAP; tests the degree to which fidelity can be maintained using the DAP compared to implementation as usual (IAU); and examines the feasibility of using automated phone or internet-enabled, computer-based technology to assess intervention fidelity and client satisfaction. The study design incorporates mixed methods in order to describe processes and factors associated with variations in both how the DAP itself is implemented and how the DAP impacts fidelity, drift, and adaptation. The DAP model is to be examined by assigning six regions in California (USA) to either the DAP (n = 3) or IAU (n = 3) to implement an EBP to prevent child neglect.
Discussion
The DAP represents a data-informed, collaborative, multiple stakeholder approach to maintain intervention fidelity during the implementation of EBPs in the field by providing support for intervention, system, and organizational adaptation and intervention fidelity to meet local needs. This study is designed to address the real-world implications of EBP implementation in public sector service systems and is relevant for national, state, and local service systems and organizations.
Implementing treatments and interventions with demonstrated effectiveness is critical for improving patient health outcomes at a reduced cost. When an evidence-based intervention (EBI) is implemented with fidelity in a setting that is very similar to the setting wherein it was previously found to be effective, it is reasonable to anticipate similar benefits of that EBI. However, one goal of implementation science is to expand the use of EBIs as broadly as is feasible and appropriate in order to foster the greatest public health impact. When implementing an EBI in a novel setting, or targeting novel populations, one must consider whether there is sufficient justification that the EBI would have similar benefits to those found in earlier trials.
Discussion
In this paper, we introduce a new concept for implementation called “scaling-out” when EBIs are adapted either to new populations or new delivery systems, or both. Using existing external validity theories and multilevel mediation modeling, we provide a logical framework for determining what new empirical evidence is required for an intervention to retain its evidence-based standard in this new context. The motivating questions are whether scale-out can reasonably be expected to produce population-level effectiveness as found in previous studies, and what additional empirical evaluations would be necessary to test for this short of an entirely new effectiveness trial. We present evaluation options for assessing whether scaling-out results in the ultimate health outcome of interest.
Conclusion
In scaling to health or service delivery systems or population/community contexts that are different from the setting where the EBI was originally tested, there are situations where a shorter timeframe of translation is possible. We argue that implementation of an EBI in a moderately different setting or with a different population can sometimes “borrow strength” from evidence of impact in a prior effectiveness trial. The collection of additional empirical data is deemed necessary by the nature and degree of adaptations to the EBI and the context. Our argument in this paper is conceptual, and we propose formal empirical tests of mediational equivalence in a follow-up paper.
To describe adaptations that community-based organizations (CBOs) made to evidence-based chronic disease prevention intervention programs and to discuss reasons for those adaptations.
Design:
The process evaluation used project report forms, interviews, and focus groups to obtain information from organizational staff.
Setting:
Programs were conducted in community-based organizations (n = 12) in rural southwest Georgia including churches, worksites, community coalitions, a senior center, and a clinical patient setting.
Participants:
Site coordinators (n = 15), organizational leaders (n = 7), and project committee members (n = 25) involved in program implementation at 12 funded organizations. Intervention: The Emory Cancer Prevention and Control Research Network awarded mini grants to rural CBOs to implement one of 5 evidence-based nutrition or physical activity programs. These sites received funding and technical assistance from Emory and agreed to conduct all required elements of the selected evidence-based program.
Main Outcome Measures:
Program implementation and context were explored, including completion of core elements, program adaptation, and reasons for adaptation that occurred at sites implementing evidence-based chronic disease prevention programs.
Results:
Five major types of adaptations were observed: changing educational materials, intended audience, and program delivery; adding new activities; and deleting core elements. Sites had intentional or unintentional reasons for making program adaptations including enhancing engagement in the program, reaching specific audiences, increasing program fit, and reinforcing program messages. Reasons for not completing core elements (program deletions) included various types of “turbulence” or competing demands (eg, leadership/staff transitions and time constraints).
Conclusions:
The types of adaptations and reasons described in this evaluation support the idea that adaptation is a natural element of implementing evidence-based interventions. Building this understanding into dissemination strategies may help researchers and funders better reach communities with evidence-based interventions that are a relevant fit, while striving for fidelity.
Adaptations of evidence-based interventions (EBIs) often occur. However, little is known about the reasons for adaptation, the adaptation process, and outcomes of adapted EBIs. To address this gap, we conducted a systematic review to answer the following questions: (1) What are the reasons for and common types of adaptations being made to EBIs in community settings as reported in the published literature? (2) What steps are described in making adaptations to EBIs? and (3) What outcomes are assessed in evaluations of adapted EBIs?
Methods
We conducted a systematic review of English language publications that described adaptations of public health EBIs. We searched Ovid PubMed, PsycINFO, PsycNET, and CINAHL and citations of included studies for adapted public health EBIs. We abstracted characteristics of the original and adapted populations and settings, reasons for adaptation, types of modifications, use of an adaptation framework, adaptation steps, and evaluation outcomes. Results Forty-two distinct EBIs were found focusing on HIV/AIDS, mental health, substance abuse, and chronic illnesses. More than half (62%) reported on adaptations in the USA. Frequent reasons for adaptation included the need for cultural appropriateness (64.3%), focusing on a new target population (59.5%), and implementing in a new setting (57.1%). Common adaptations were content (100%), context (95.2%), cultural modifications (73.8%), and delivery (61.9%). Most study authors conducted a community assessment, prepared new materials, implemented the adapted intervention, evaluated or planned to evaluate the intervention, determined needed changes, trained staff members, and consulted experts/stakeholders. Most studies that reported an evaluation (k = 36) included behavioral outcomes (71.4%), acceptability (66.7%), fidelity (52.4%), and feasibility (52.4%). Fewer measured adoption (47.6%) and changes in practice (21.4%).
Conclusions
These findings advance our understanding of the patterns and effects of modifications of EBIs that are reported in published studies and suggest areas of further research to understand and guide the adaptation process. Furthermore, findings can inform better reporting of adapted EBIs and inform capacity building efforts to assist health professionals in adapting EBIs.
Ethnography has been proposed as a valuable method for understanding how implementation occurs within dynamic healthcare contexts, yet this method can be time-intensive and challenging to operationalize in pragmatic implementation. The current study describes an ethnographically-informed method of guided discussions developed for use by a multi-project national implementation program.
Methods
The EMPOWER QUERI is conducting three projects to implement innovative care models in VA women’s health for high-priority health concerns – prediabetes, cardiovascular risk, and mental health – utilizing the Replicating Effective Programs (REP) implementation strategy enhanced with stakeholder engagement and complexity science. Drawing on tenets of ethnographic research, we developed a lightly-structured method of guided “periodic reflections” to aid in documenting implementation phenomena over time. Reflections are completed as 30–60 min telephone discussions with implementation team members at monthly or bi-monthly intervals, led by a member of the implementation core. Discussion notes are coded to reflect key domains of interest and emergent themes, and can be analyzed singly or in triangulation with other qualitative and quantitative assessments to inform evaluation and implementation activities.
Results
Thirty structured reflections were completed across the three projects during a 15-month period spanning pre-implementation, implementation, and sustainment activities. Reflections provide detailed, near-real-time information on projects’ dynamic implementation context, including characteristics of implementation settings and changes in the local or national environment, adaptations to the intervention and implementation plan, and implementation team sensemaking and learning. Reflections also provide an opportunity for implementation teams to engage in recurring reflection and problem-solving.
The editorial aims to provide a brief overview of the individual contributions to this special issue, and a commentary on the contributions in terms of their contribution to the broader issue relating fidelity and adaptation to health promotion research, policy and practice.
Design/methodology/approach
This is the first special issue with a focus on fidelity and adaptation. Researchers who have recently examined these issues were invited to submit papers that described recent findings to this special issue of Health Education. Following the traditional double blinded peer review process, five submissions were accepted for publication.
Findings
The papers in this issue contribute each in their distinctive way to advancing our understanding of the relative influence that fidelity and adaptation have on moderating outcomes of health education programmes. Fidelity and adaptation must be thought of as independent constructs, each of which influences the outcomes of interventions delivered in school and community settings. Originality/value This compilation of papers is the first to systematically address both fidelity and adaptation. Practitioners and researchers alike will gain increased understanding of the potential for fidelity and adaptation to affect outcomes.
Implementation science is shifting from qualifying adaptations as good or bad towards understanding adaptations and their impact. Existing adaptation classification frameworks are largely descriptive (e.g., who made the adaptation) and geared towards researchers. They do not help practitioners in decision-making around adaptations (e.g., is an adaptation likely to have negative impacts? Should it be pursued?). Moreover, they lack constructs to consider “ripple effects” of adaptations (i.e., both intended and unintended impacts on outcomes, recognizing that an adaptation designed to have a positive impact on one outcome may have unintended impacts on other outcomes). Finally, they do not specify relationships between adaptations and outcomes, including mediating and moderating relationships. The objective of our research was to promote systematic assessment of intended and unintended impacts of adaptations by using existing frameworks to create a model that proposes relationships among constructs.
Materials and methods
We reviewed, consolidated, and refined constructs from two adaptation frameworks and one intervention-implementation outcome framework. Using the consolidated and refined constructs, we coded qualitative descriptions of 14 adaptations made to an existing evidence-based intervention; the 14 adaptations were designed in prior research by a stakeholder panel using a modified Delphi approach. Each of the 14 adaptations had detailed descriptions, including the nature of the adaptation, who made it, and its goal and reason. Using coded data, we arranged constructs from existing frameworks into a model, the Model for Adaptation Design and Impact (MADI), that identifies adaptation characteristics, their intended and unintended impacts (i.e., ripple effects), and potential mediators and moderators of adaptations’ impact on outcomes. We also developed a decision aid and website (MADIguide.org) to help implementation scientists apply MADI in their work.
Results and conclusions
Our model and associated decision aids build on existing frameworks by comprehensively characterizing adaptations, proposing how adaptations impact outcomes, and offering practical guidance for designing adaptations. MADI encourages researchers to think about potential causal pathways of adaptations (e.g., mediators and moderators) and adaptations’ intended and unintended impacts on outcomes. MADI encourages practitioners to design adaptations in a way that anticipates intended and unintended impacts and leverages best practice from research.
Sustainable shifts in population behaviours require system-level implementation and embeddedness of large-scale health interventions. This paper aims to understand how different contexts of scaling up interventions affect mechanisms to produce intended and unintended scale up outcomes.
Methods
A mixed method study combining a realist perspective and systems analysis (causal loop diagrams) of scaled-up physical activity and/or nutrition interventions implemented at a state/national level in Australia (2010–18). The study involved four distinct phases: Phase 1 expert consultation, database and grey literature searches to identify scaled-up interventions; Phase 2 generating initial Context-Mechanism-Outcome configurations (CMOs) from the WHO ExpandNet framework for scaling up; Phase 3 testing and refining CMOs via online surveys and realist interviews with academics, government and non-government organisations (NGOs) involved in scale up of selected interventions (Phase 1); and Phase 4 generating cross-case mid-range theories represented in systems models of scaling up; validated by member checking. Descriptive statistics were reported for online survey data and realist analysis for interview data.
Results
Seven interventions were analysed, targeting nutrition (n = 1), physical activity (n = 1), or a combination (n = 5). Twenty-six participants completed surveys; 19 completed interviews. Sixty-three CMO pathways underpinned successful scale up, reflecting 36 scale up contexts, 8 key outcomes; linked via 53 commonly occurring mechanisms. All five WHO framework domains were represented in the systems models. Most CMO pathways included ‘intervention attributes’ and led to outcomes ‘community sustainability/embeddedness’ and ‘stakeholder buy-in/perceived value’. Irrespective of interventions being scaled in similar contexts (e.g., having political favourability); mechanisms still led to both intended and unintended scale up outcomes (e.g., increased or reduced sustainability).
Conclusion
This paper provides the first evidence for mechanisms underpinning outcomes required for successful scale up of state or nationally delivered interventions. Our findings challenge current prerequisites for effective scaling suggesting other conditions may be necessary. Future scale up approaches that plan for complexity and encourage iterative adaptation throughout, may enhance scale up outcomes. Current linear, context-to-outcome depictions of scale up oversimplify what is a clearly a complex interaction between perceptions, worldviews and goals of those involved. Mechanisms identified in this study could potentially be leveraged during future scale up efforts, to positively influence intervention scalability and sustainability.
Keywords Diaries, action research, district health management teams, Ghana, Tanzania, Uganda
Evidence-based interventions are frequently modified or adapted during the implementation process. Changes may be made to protocols to meet the needs of the target population or address differences between the context in which the intervention was originally designed and the one into which it is implemented [Addict Behav 2011, 36(6):630–635]. However, whether modification compromises or enhances the desired benefits of the intervention is not well understood. A challenge to understanding the impact of specific types of modifications is a lack of attention to characterizing the different types of changes that may occur. A system for classifying the types of modifications that are made when interventions and programs are implemented can facilitate efforts to understand the nature of modifications that are made in particular contexts as well as the impact of these modifications on outcomes of interest.
Methods
We developed a system for classifying modifications made to interventions and programs across a variety of fields and settings. We then coded 258 modifications identified in 32 published articles that described interventions implemented in routine care or community settings.
Results
We identified modifications made to the content of interventions, as well as to the context in which interventions are delivered. We identified 12 different types of content modifications, and our coding scheme also included ratings for the level at which these modifications were made (ranging from the individual patient level up to a hospital network or community). We identified five types of contextual modifications (changes to the format, setting, or patient population that do not in and of themselves alter the actual content of the intervention). We also developed codes to indicate who made the modifications and identified a smaller subset of modifications made to the ways that training or evaluations occur when evidence-based interventions are implemented. Rater agreement analyses indicated that the coding scheme can be used to reliably classify modifications described in research articles without overly burdensome training.
Conclusions
This coding system can complement research on fidelity and may advance research with the goal of understanding the impact of modifications made when evidence-based interventions are implemented. Such findings can further inform efforts to implement such interventions while preserving desired levels of program or intervention effectiveness.
The implementation of evidence-based guidelines can improve clinical and public health outcomes by helping health professionals practice in the most effective manner, as well as assisting policy-makers in designing optimal programs. Adaptation of a guideline to suit the context in which it is intended to be applied can be a key step in the implementation process. Without taking the local context into account, certain interventions recommended in evidence-based guidelines may be infeasible under local conditions. Guideline adaptation frameworks provide a systematic way of approaching adaptation, and their use may increase transparency, methodological rigor, and the quality of the adapted guideline. This paper presents a number of adaptation frameworks that are currently available. We aim to compare the advantages and limitations of their processes, methods, and resource implications. These insights into adaptation frameworks can inform the future development of guidelines and systematic methods to optimize their adaptation.
Analysis
Recent adaptation frameworks show an evolution from adapting entire existing guidelines, to adapting specific recommendations extracted from an existing guideline, to constructing evidence tables for each recommendation that needs to be adapted. This is a move towards more recommendation-focused, context-specific processes and considerations. There are still many gaps in knowledge about guideline adaptation. Most of the frameworks reviewed lack any evaluation of the adaptation process and outcomes, including user satisfaction and resources expended. The validity, usability, and health impact of guidelines developed via an adaptation process have not been studied. Lastly, adaptation frameworks have not been evaluated for use in low-income countries.
Conclusion
Despite the limitations in frameworks, a more systematic approach to adaptation based on a framework is valuable, as it helps to ensure that the recommendations stay true to the evidence while taking local needs into account. The utilization of frameworks in the guideline implementation process can be optimized by increasing the understanding and upfront estimation of resource and time needed, capacity building in adaptation methods, and increasing the adaptability of the source recommendation document.
This report argues that if we are to avoid reproducing the pattern of uneven progress that has characterised the MDG campaign, there must be more explicit recognition of the political conditions that sometimes enable, but so often obstruct, development progress. In this context, domestic reformers and their international partners must pursue innovative and politically smart ways to tackle the most intractable problems.
Key findings:
The global discussion around the post-2015 agenda has recognised the need to adjust to a changed and changing global context. However, there are key areas where the SDG discussion is not inviting different commitments, but is still focused on more of the same. A key danger is that discussions of what it will take to achieve the new goals will, once again, centre on financing gaps. During the pursuit of the MDGs, this focus reinforced the belief that inadequacies in provision could be dealt with easily enough if there was enough new funding on the table. Today, with higher rates of economic growth in many parts of the developing world, there is a new temptation to assume that growth, by itself, will take care of the problem. There is also a growing recognition that it is the function as well as the form of institutions that matters for translating resources into results. But, on international platforms, there is a lack of realism about the type of change processes and the institutional adjustments that have been linked to development breakthroughs in recent times and in past history. This fuels illusions about how easy it is going to be, in a typical poor country, to tackle gaps and inequities. The evidence base for doing things differently needs to become stronger, and more needs to be said and debated about the scope for taking these different approaches to scale. Changes in domestic politics and policy processes are by far the most important drivers of development outcomes and improvements in service delivery. Donors can help reform processes to adopt a problem-driven and adaptive approach, but if they are to be effective they must act as facilitators and brokers of locally led processes of change, not as managers.
Recommendations:
Aid should do more to support initiatives that are problem-driven, adaptive and locally led. These initiatives need financial and other support that is fit for that purpose. This means not only tracking MDG-type development outcomes but also monitoring and building up an understanding of the intermediate changes in process that are most effective in improving those outcomes. Measures of how ‘adaptive’ or ‘locally led’ aid programmes are would be a good start. There are many areas where spending that benefits poor countries could be increased, but the current debate about targets for aid spending is too focused on the ability of the donor country to pay, rather than whether those funds are used effectively. Looking at how aid works is more important than how much to spend.
Country Government Ownership
Should I consider working with government to address the social problem? If so, in which role?
Who within the government holds the decision-making power and what‘s my strategy to get them on board?
Which proven tactics can help increase awareness, willingness and capacity to take action of our government counterparts?
Are there resources that can support me in such working with government?
Donors are increasingly interested in the transition and sustainability of global health programs as priorities shift and external funding declines. Systematic and high-quality monitoring and evaluation (M&E) of such processes is rare. We propose a framework and related guiding questions to systematize the M&E of global health program transitions.
Methods:
We conducted stakeholder interviews, searched the peer-reviewed and gray literature, gathered feedback from key informants, and reflected on author experiences to build a framework on M&E of transition and to develop guiding questions.
Findings:
The conceptual framework models transition as a process spanning pre-transition and transition itself and extending into sustained services and outcomes. Key transition domains include leadership, financing, programming, and service delivery, and relevant activities that drive the transition in these domains forward include sustaining a supportive policy environment, creating financial sustainability, developing local stakeholder capacity, communicating to all stakeholders, and aligning programs. Ideally transition monitoring would begin prior to transition processes being implemented and continue for some time after transition has been completed. As no set of indicators will be applicable across all types of health program transitions, we instead propose guiding questions and illustrative quantitative and qualitative indicators to be considered and adapted based on the transition domains identified as most important to the particular health program transition. The M&E of transition faces new and unique challenges, requiring measuring constructs to which evaluators may not be accustomed. Many domains hinge on measuring “intangibles” such as the management of relationships. Monitoring these constructs may require a compromise between rigorous data collection and the involvement of key stakeholders.
Conclusion:
Monitoring and evaluating transitions in global health programs can bring conceptual clarity to the transition process, provide a mechanism for accountability, facilitate engagement with local stakeholders, and inform the management of transition through learning. Further investment and stronger methodological work are needed.
During 2009-2012, Avahan, a large donor funded HIV/AIDS prevention program in India was transferred from donor support and operation to government. This transition of approximately 200 targeted interventions (TIs), occurred in three tranches in 2009, 2011 and 2012. This paper reports on the management practices pursued in support of a smooth transition of the program, and addresses the extent to which standard change management practices were employed, and were useful in supporting transition.
Results
We conducted structured surveys of a sample of 80 TIs from the 2011 and 2012 rounds of transition. One survey was administered directly before transition and the second survey 12 month after transition. These surveys assessed readiness for transition and practices post-transition. We also conducted 15 case studies of transitioning TIs from all three rounds, and re-visited 4 of these 1-3 years later.
Results
Considerable evolution in the nature of relationships between key actors was observed between transition rounds, moving from considerable mistrust and lack of collaboration in 2009 toward a shared vision of transition and mutually respectful relationships between Avahan and government in later transition rounds. Management practices also evolved with the gradual development of clear implementation plans, establishment of the post of “transition manager” at state and national levels, identified budgets to support transition, and a common minimum programme for transition. Staff engagement was important, and was carried out relatively effectively in later rounds. While the change management literature suggests short-term wins are important, this did not appear to be the case for Avahan, instead a difficult first round of transition seemed to signal the seriousness of intentions regarding transition.
Conclusions
In the Avahan case a number of management practices supported a smooth transition these included: an extended and sequenced time frame for transition; co-ownership and planning of transition by both donor and government; detailed transition planning and close attention to program alignment, capacity development and communication; engagement of staff in the transition process; engagement of multiple stakeholders post transition to promote program accountability and provide financial support; signaling by actors in charge of transition that they were committed to specified time frames.
Systematic transition criteria: A clear set of criteria needs to be developed for assessment of a country’s transition preparedness. Publicly available transition schedules: Transition should be discussed between donors and representatives of the country to determine start and end dates and duration of transition. Coordinated donor decisions: Donors need a clearer mechanism to communicate their transition plans about a particular country with each other. March 2016 Transitions from donor funding to domestic reliance for HIV responses 6 “Good practice” transitions require: Time: Not only is a period of several (5-10) years required, but also a phased roadmap to achieve various specified financial and operational targets is needed. High-level political commitment: Without commitment at the highest political levels, transitions can be easily derailed by changes in staffing, in political parties, in economic circumstances, etc. Country ownership: Aligning donor-funded projects with national policy as well as with the national context is important if projects are to be absorbed by domestic bill-payers. Built-in monitoring and evaluation: M&E is needed to assess progress against the roadmap targets, as well as to track changes to the epidemic, issues affecting the testing and treatment cascade, access by key populations to essential services, and other important considerations. Transitions that promote and protect human rights are most likely to maintain and expand access to essential HIV services by key populations through: Funding mechanisms for NGOs, which must be in place and working effectively to enable access to sufficient funds for key population service delivery programs. High-level political engagement, specifically related to the costs and benefits of excluding or including specific key populations in national HIV responses. Improved in-country capacity for advocacy based on data collection and analysis by NGOs or community-based networks representing each relevant key population. Increased capacity of NGOs to demonstrate specifically the level and types of activities they will undertake in the HIV prevention and treatment cascade to justify the sustained allocation. Ensured funding for police, security, and criminal justice reform programs because these structural elements have the strongest influence in most countries over access of key populations to needed services.
Donors have long wanted to shift programs to local ownership. But the shift has been problematic. Programs are still largely donor-driven. Full local ownership is unlikely, but collaborative partnership of donors and local entities is a proven model that can both improve health and promote civil society. If donors expect sustained advocacy after their support ends, they need to support capacity building directly or through higher indirect cost allowances. Depending on their investment aims, donors can choose from four options for strengthening local capacity for partnership. A proposed model for strengthening local advocacy capacity worldwide envisions a global project, regional advocacy hubs, and networks of local NGOs.
During the last decade, donor governments and international agencies have increasingly emphasized the importance of building the capacity of indigenous health care organizations as part of strengthening health systems and ensuring sustainability. In 2009, the U.S. Global Health Initiative made country ownership and capacity building keystones of U.S. health development assistance, and yet there is still a lack of consensus on how to define either of these terms, or how to implement “country owned capacity building”.
Discussion
Concepts around capacity building have been well developed in the for-profit business sector, but remain less well defined in the non-profit and social sectors in low and middle-income countries. Historically, capacity building in developing countries has been externally driven, related to project implementation, and often resulted in disempowerment of local organizations rather than local ownership. Despite the expenditure of millions of dollars, there is no consensus on how to conduct capacity building, nor have there been rigorous evaluations of capacity building efforts. To shift to a new paradigm of country owned capacity building, donor assistance needs to be inclusive in the planning process and create true partnerships to conduct organizational assessments, analyze challenges to organizational success, prioritize addressing challenges, and implement appropriate activities to build new capacity in overcoming challenges. Before further investments are made, a solid evidence base should be established concerning what works and what doesn’t work to build capacity.
Summary
Country-owned capacity building is a relatively new concept that requires further theoretical exploration. Documents such as The Paris Declaration on Aid Effectiveness detail the principles of country ownership to which partner and donor countries should commit, but do not identify the specific mechanisms to carry out these principles. More evidence as to how country-owned capacity building plays out in practice is needed to guide future interventions. The Global Health Initiative funding that is currently underway is an opportunity to collect evaluative data and establish a centralized and comprehensive evidence base that could be made available to guide future country-owned capacity building efforts.
This document is based on a series of six virtual events that took place from April to November 2021, organized by the CoP’s Monitoring and Evaluation Working Group (MEWG), one of the CoP’s nine working groups. The webinars, and the current working paper, emerged from a recognition that recent attention by donor agencies, foundations and NGOs to the need for scaling improved practices by institutionalizing those changes in government agencies have not been accompanied by comparable attention to the role of M&E, and the role of “evidence” more generally, in facilitating that institutionalization.
The goal of this document is to present the rich and critical insights emerging during the 2021 webinar series. The first draft was developed through careful review and culling from the presentation recordings which are listed in the annex on page 14 by a consultant on behalf of the CoP. The series presenters spoke from their practical experience supporting efforts to institutionalize within government health and education interventions that were incubated in NGOs. They represent, we believe, a useful point of departure for the MEWG, the CoP, and the larger development community to engage a range of issues not fully addressed in the initial 6 webinars or in this paper. Given the critical importance to the development field of better understanding what makes institutionalization succeed generally, the CoP has as a goal to continue and expand its deep dive on this topic.
The CSC brings service users and service providers together along with local government to identify service utilization and provision challenges, mutually generate and execute shared solutions, and track effectiveness of those solutions in an ongoing process of quality improvement. Since its initial development by CARE Malawi in 2002, the CSC has been used in more than 15 countries in Africa, Asia and South America across service sectors including natural resource management, education, and water and sanitation.
Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition.
Methods:
We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas.
Findings:
In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level. Conclusion: Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.
Donors commonly fund innovative interventions to improve health in the hope that governments of low and middle-income countries will scale-up those that are shown to be effective. Yet innovations can be slow to be adopted by country governments and implemented at scale. Our study explores this problem by identifying key contextual factors influencing scale-up of maternal and newborn health innovations in three low-income settings: Ethiopia, the six states of northeast Nigeria and Uttar Pradesh state in India. Methods We conducted 150 semi-structured interviews in 2012/13 with stakeholders from government, development partner agencies, externally funded implementers including civil society organisations, academic institutions and professional associations to understand scale-up of innovations to improve the health of mothers and newborns these study settings. We analysed interview data with the aid of a common analytic framework to enable cross-country comparison, with Nvivo to code themes.
Results
We found that multiple contextual factors enabled and undermined attempts to catalyse scale-up of donor-funded maternal and newborn health innovations. Factors influencing government decisions to accept innovations at scale included: how health policy decisions are made; prioritising and funding maternal and newborn health; and development partner harmonisation. Factors influencing the implementation of innovations at scale included: health systems capacity in the three settings; and security in northeast Nigeria. Contextual factors influencing beneficiary communities’ uptake of innovations at scale included: sociocultural contexts; and access to healthcare.
Conclusions
We conclude that context is critical: externally funded implementers need to assess and adapt for contexts if they are to successfully position an innovation for scale-up.
Donors often fund projects that develop innovative practices in low and middle-income countries, hoping recipient governments will adopt and scale them within existing systems and programmes. Such innovations frequently end when project funding ends, limiting longer term potential in countries with weak health systems and pressing health needs. This paper aims to identify critical actions for externally funded project implementers to enable scale-up of maternal and newborn child health innovations originally funded by the Bill & Melinda Gates Foundation (‘the foundation’), or influenced by innovations that were originally funded by the foundation in three low-income settings: Ethiopia, the state of Uttar Pradesh in India and northeast Nigeria. We define scale-up as the adoption of donor-funded innovations beyond their original project settings and time periods. Methods We conducted 71 in-depth, semi-structured interviews with representatives from government, donors and other development partner agencies, donor-funded implementers including frontline providers, research organisations and professional associations. We explored three case study maternal and newborn innovations. Selection criteria were: a) innovations originally funded by the Bill & Melinda Gates Foundation (‘the foundation’), or influenced by innovations that were originally funded by the foundation; b) innovations for which a decision to scale-up had been made, allowing us to reflect on the factors influencing those decisions; c) innovations with increased geographical reach, benefitting a greater number of people, beyond districts where foundation-funded implementers were active. Our data were analysed based on a common analytic framework to aid cross-country comparisons.
Results
Based on study respondents’ accounts, we identified six critical steps that donor-funded implementers had taken to enable the adoption of maternal and newborn health innovations at scale: designing innovations for scale; generating evidence to influence and inform scale-up; harnessing the support of powerful individuals; being prepared for scale-up and responsive to change; ensuring continuity by being part of the transition to scale; and embracing the aid effectiveness principles of country ownership, alignment and harmonisation.
Conclusions
Six critical actions identified in this study were associated with adopting and scaling maternal and newborn health innovations. However, scale-up is unpredictable and depends on factors outside implementers’ control.
Dr. Chibi shared his views during a dialogue led by Catalyst 2030, a global movement of social change innovators working to accelerate achievement of the SDGs. Catalyst 2030 will present propositions to the UN Taskforce and governments for a potential UN Resolution next month.
Despite the rapid increase in facility deliveries in Uganda, the number of adverse birth outcomes (e.g., neonatal and maternal deaths) has remained high. We aimed to codesign and co-implement a locally designed package of interventions to improve the quality of care in hospitals in the Busoga region.
Design and Implementation:
This project was designed and implemented in 3 phases in the 6 main hospitals in east-central Uganda from 2013 to 2016. First, the inception phase engaged health system managers to codesign the intervention. Second, the implementation phase involved training health providers, strengthening the data information system, and providing catalytic equipment and medicines to establish newborn care units (NCUs) within the existing infrastructure. Third, the hospital collaborative phase focused on clinical mentorship, maternal and perinatal death reviews (MPDRs), and collaborative learning sessions.
Achievements:
In all 6 participating hospitals, we achieved institutionalization of NCUs in maternity units by establishing kangaroo mother care areas, resuscitation corners, and routine MPDRs. These improvements were associated with reduced maternal and neonatal deaths. Facilitators of success included a simple, low-cost, and integrated package designed with local health managers; the emergence of local neonatal care champions; implementation and support over a reasonably long period; decentralization of newborn care services; and use of mainly existing local resources (e.g., physical space, human resources, and commodities). Barriers to success related to limited hospital resources, unstable electricity, and limited participation from doctors. More advanced NCUs have been established in 3 of the 6 hospitals, and 7 high-volume comprehensive health centers have been established with functional NCUs.
Conclusion:
The involvement of local health workers and leaders was the foundation for designing, sustaining, and scaling up feasible interventions by harnessing available resources. These findings are relevant for the quality of care improvement efforts in Uganda and other resource-restrained settings.
“Business innovation produces some kinds of transformation well, and government policy innovation does others. Each has limits. But many imperatives sit in the space between the two modes.”
– Roger Martin and Sally Osberg in Getting Beyond Better
So how, within this space, can social enterprises and government partner together to dramatically scale impact? CASE explored this question with leading social ventures from the Skoll Foundation and USAID portfolios in its newest contribution to the Scaling Pathways theme study series, Leveraging Government Partnerships for Scaled Impact.
Sustainability
While many studies have implemented programs to increase sanitation coverage throughout the world, there are limited rigorous studies on the sustainability of these sanitation programs.
Methods:
Between 2014 and 2018, the rural Sustainable Sanitation and Hygiene for All (SSH4A) approach was implemented by SNV in sub-Saharan Africa and Asia. Repeated cross-sectional household surveys were administered annually throughout program implementation and 1 to 2 years following completion of program activities. We characterize to what extent sanitation coverage was sustained 1 to 2 years after implementation of this SSH4A intervention.
Results:
Surveys were conducted in 12 program areas in 10 countries, with 22,666 households receiving a post-implementation survey. Six of 12 program areas (Bhutan, Ghana, Kenya, both Nepal sites, Tanzania) had similar coverage levels of basic sanitation 1–2 years post-implementation, whereas there were varying levels of slippage in the other program areas (both Ethiopia sites, Indonesia, Mozambique, Uganda, Zambia), ranging from a drop of 63 percentage points in coverage in Ethiopia to a drop of only 4 percentage points in Indonesia. In countries that experienced losses in the coverage of household sanitation, sanitation sharing among neighbors generally did not increase, whereas open defecation did increase. In each of the areas where slippage occurred, the sanitation coverage levels at the final time point were all still higher than the initial time point before SNV started working in these areas. We found several factors to be associated with the sustainability of sanitation coverage, including household socioeconomic status, having household members with disabilities, baseline sanitation coverage levels of the program areas, and rate of change of coverage during program activities.
Conclusions:
Data revealed sustained gains in sanitation coverage in some program areas, yet slippage in other areas. This work may serve to benchmark the sustainability of sanitation interventions in sub-Saharan Africa and Asia.
Despite growth in implementation research, limited scientific attention has focused on understanding and improving sustainability of health interventions. Models of sustainability have been evolving to reflect challenges in the fit between intervention and context.
Discussion
We examine the development of concepts of sustainability, and respond to two frequent assumptions —'voltage drop,’ whereby interventions are expected to yield lower benefits as they move from efficacy to effectiveness to implementation and sustainability, and 'program drift,’ whereby deviation from manualized protocols is assumed to decrease benefit. We posit that these assumptions limit opportunities to improve care, and instead argue for understanding the changing context of healthcare to continuously refine and improve interventions as they are sustained. Sustainability has evolved from being considered as the endgame of a translational research process to a suggested 'adaptation phase’ that integrates and institutionalizes interventions within local organizational and cultural contexts. These recent approaches locate sustainability in the implementation phase of knowledge transfer, but still do not address intervention improvement as a central theme. We propose a Dynamic Sustainability Framework that involves: continued learning and problem solving, ongoing adaptation of interventions with a primary focus on fit between interventions and multi-level contexts, and expectations for ongoing improvement as opposed to diminishing outcomes over time.
Summary
A Dynamic Sustainability Framework provides a foundation for research, policy and practice that supports development and testing of falsifiable hypotheses and continued learning to advance the implementation, transportability and impact of health services research.
In a previous trial in Vietnam, a facilitation strategy to secure evidence-based practice in primary care resulted in reduced neonatal mortality over a period of three years. While little is known as to what ensures sustainability in the implementation of community-based strategies, the aim of this study was to investigate factors promoting or hindering implementation, and sustainability of knowledge implementation strategies, by means of the former Neonatal Knowledge Into Practice (NeoKIP) trial.
Methods
In 2014 we targeted all levels in the Vietnamese healthcare system: six individual interviews with representatives at national, provincial and district levels, and six focus group discussions with representatives at the commune level. The interviews were transcribed verbatim, translated to English, and analysed using inductive and deductive thematic analysis.
Results
To achieve successful implementation and sustained effect of community-based knowledge implementation strategies, engagement of leaders and key stakeholders at all levels of the healthcare system is vital–prior to, during and after a project. Implementation and sustainability require thorough needs assessment, tailoring of the intervention, and consideration of how to attain and manage funds. The NeoKIP trial was characterised by a high degree of engagement at the primary healthcare system level. Further, three years post trial, maternal and neonatal care was still high on the agenda for healthcare workers and leaders, even though primary aspects such as stakeholder engagement at all levels, and funding had been incomplete or lacking.
Conclusions
The current study illustrates factors to support successful implementation and sustain effects of community-based strategies in projects in low- and middle-income settings; some but not all factors were represented during the post-NeoKIP era. Most importantly, trials in this and similar contexts require deliberate management throughout and beyond the project lifetime, and engagement of key stakeholders, in order to promote and sustain knowledge implementation.
Saving Mothers, Giving Life (SMGL) significantly reduced maternal and perinatal mortality in Uganda and Zambia by using a district health systems strengthening approach to address the key delays women and newborns face in receiving quality, timely, and appropriate medical care. This article documents the transition of SMGL from pilot to scale in Uganda and Zambia and analyzes the sustainability of the approach, examining the likelihood of maintaining positive trends in maternal and newborn health in both countries.
Methods:
We analyzed the potential sustainment of SMGL achievements using a tool adapted from the HIV-focused domains and elements of the U.S. President's Emergency Plan for AIDS Relief Sustainability Index and Dashboard for maternal and neonatal health pro-gramming adding a domain on community normative change. Information for each of the 5 resulting domains was drawn from SMGL and non-SMGL reports, individual stakeholder interviews, and group discussions.
Findings:
In both Uganda and Zambia, the SMGL proof-of-concept phase catalyzed commitment to saving mothers and newborns and a renewed belief that significant change is possible. Increased leadership and accountability for maternal and newborn health, particularly at the district and facility levels, was bolstered by routine maternal death surveillance reviews that engaged a wide range of local leadership. The SMGL district-strengthening model was found to be cost-effective with cost of death averted estimated at US$177-206 per year of life gained. When further considering the ripple effect that saving a mother has on child survival and the household economy, the value of SMGL increases. Ministries of health and donor agencies have already demonstrated a willingness to pay this amount per year of life for other programs, such as HIV and AIDS.
Conclusion:
As SMGL scaled up in both Uganda and Zambia, the intentional integration of SMGL interventions into host country systems, alignment with other large-scale programs, and planned reductions in annual SMGL funding all contributed to increasing host government ownership of the interventions and set the SMGL approach on a path more likely to be sustained following the close of the initiative. Lessons from the learning districts resulted in increased efficiency in allocation of resources for maternal and newborn health, better use of strategic information, improved management capacities, and increased community engagement.
Sub-Saharan Africa (SSA) is facing a double burden of disease with a rising prevalence of non-communicable diseases (NCDs) while the burden of communicable diseases (CDs) remains high. Despite these challenges, there remains a significant need to understand how or under what conditions health interventions implemented in sub-Saharan Africa are sustained. The purpose of this study was to conduct a systematic review of empirical literature to explore how health interventions implemented in SSA are sustained.
Methods
We searched MEDLINE, Biological Abstracts, CINAHL, Embase, PsycInfo, SCIELO, Web of Science, and Google Scholar for available research investigating the sustainability of health interventions implemented in sub-Saharan Africa. We also used narrative synthesis to examine factors whether positive or negative that may influence the sustainability of health interventions in the region.
Results
The search identified 1819 citations, and following removal of duplicates and our inclusion/exclusion criteria, only 41 papers were eligible for inclusion in the review. Twenty-six countries were represented in this review, with Kenya and Nigeria having the most representation of available studies examining sustainability. Study dates ranged from 1996 to 2015. Of note, majority of these studies (30 %) were published in 2014. The most common framework utilized was the sustainability framework, which was discussed in four of the studies. Nineteen out of 41 studies (46 %) reported sustainability outcomes focused on communicable diseases, with HIV and AIDS represented in majority of the studies, followed by malaria. Only 21 out of 41 studies had clear definitions of sustainability. Community ownership and mobilization were recognized by many of the reviewed studies as crucial facilitators for intervention sustainability, both early on and after intervention implementation, while social and ecological conditions as well as societal upheavals were barriers that influenced the sustainment of interventions in sub-Saharan Africa.
Conclusion
The sustainability of health interventions implemented in sub-Saharan Africa is inevitable given the double burden of diseases, health care worker shortage, weak health systems, and limited resources. We propose a conceptual framework that draws attention to sustainability as a core component of the overall life cycle of interventions implemented in the region.
While known efficacious preventive health interventions exist, the current capacity to scale up these interventions is limited. In recent years, much attention has focussed on developing frameworks and methods for scale-up yet, in practice, the pathway for scale-up is seldom linear and may be highly dependent on contextual circumstances. Few studies have examined the process of scaling up from decision to implementation nor examined the sustainability of scaled-up interventions. This study explores decision-makers’ perceptions from real-world scaled-up case studies to examine how scale-up decisions were made and describe enablers of successful scale-up and sustainability.
Methods
This qualitative study included 29 interviews conducted with purposively sampled key Australian policy-makers, practitioners and researchers experienced in scale-up. Semi-structured interview questions obtained information regarding case studies of scaled-up interventions. The Framework Analysis method was used as the primary method of analysis of the interview data to inductively generate common and divergent themes within qualitative data across cases.
Results
A total of 31 case studies of public health interventions were described by interview respondents based on their experiences. According to the interviewees’ perceptions, decisions to scale up commonly occurred either opportunistically, when funding became available, or when a deliberate decision was made and funding allocated. The latter scenario was more common when the intervention aligned with specific political or strategic goals. Decisions to scale up were driven by a variety of key actors such as politicians, senior policy-makers and practitioners in the health system. Drivers of a successful scale-up process included good governance, clear leadership, and adequate resourcing and expertise. Establishing accountability structures and appropriate engagement mechanisms to encourage the uptake of interventions were also key enablers. Sustainability was influenced by evidence of impact as well as good acceptability among the general or target population.
Conclusions
Much like Kingdon’s Multiple Streams Theory of ‘policy windows’, there is a conceptually similar ‘window for scale-up’, driven by a complex interplay of factors such as political need, strategic context, funding and key actors. Researchers and policy-makers need to consider scalability from the outset and prepare for when the window for scale-up opens. Decision-makers need to provide longer term funding for scale-up to facilitate longer term sustainability and build on the resources already invested for the scale-up process.
Understanding sustainability is one of the significant implementation science challenges. One of the big challenges in researching sustainability is the lack of consistent definitions in the literature. Most implementation studies do not present a definition of sustainability, even when assessing sustainability. The aim of the current study was to systematically develop a comprehensive definition of sustainability based on definitions already used in the literature.
Methods
We searched for knowledge syntheses of sustainability and abstracted sustainability definitions from the articles identified through any relevant systematic and scoping reviews. The constructs in the abstracted sustainability definitions were mapped to an existing definition. The comprehensive definition of sustainability was revised to include emerging constructs.
Results
We identified four knowledge syntheses of sustainability, which identified 209 original articles. Of the 209 articles, 24 (11.5%) included a definition of sustainability. These definitions were mapped to three constructs from an existing definition, and nine new constructs emerged. We reviewed all constructs and created a revised definition: (1) after a defined period of time, (2) a program, clinical intervention, and/or implementation strategies continue to be delivered and/or (3) individual behavior change (i.e., clinician, patient) is maintained; (4) the program and individual behavior change may evolve or adapt while (5) continuing to produce benefits for individuals/systems. All 24 definitions were remapped to the comprehensive definition (percent agreement among three coders was 94%). Of the 24 definitions, 17 described the continued delivery of a program (70.8%), 17 mentioned continued outcomes (70.8%), 13 mentioned time (54.2%), 8 addressed the individual maintenance of a behavior change (33.3%), and 6 described the evolution or adaptation (25.0%).
Conclusions
We drew from over 200 studies to identify 24 existing definitions of sustainability. Based on these definitions, we identified five key sustainability constructs, which can be used as the basis for future research on sustainability. Our next step is to identify sustainability frameworks and develop a meta-framework using a concept mapping approach to consolidate the factors and considerations across sustainability frameworks.
Health information systems are central to strong health systems. They assist with patient and program management, quality improvement, disease surveillance, and strategic use of information. Many donors have worked to improve health information systems, particularly by supporting the introduction of electronic health information systems (EHIS), which are considered more responsive and more efficient than older, paper-based systems. As many donor-driven programs are increasing their focus on country ownership, sustainability of these investments is a key concern. This analysis explores the potential sustainability of EHIS investments in Malawi, Zambia and Zimbabwe, originally supported by the United States President’s Emergency Plan for AIDS Relief (PEPFAR).
Methods
Using a framework based on sustainability theories from the health systems literature, this analysis employs a qualitative case study methodology to highlight factors that may increase the likelihood that donor-supported initiatives will continue after the original support is modified or ends. Results Findings highlight commonalities around possible determinants of sustainability. The study found that there is great optimism about the potential for EHIS, but the perceived risks may result in hesitancy to transition completely and parallel use of paper-based systems. Full stakeholder engagement is likely to be crucial for sustainability, as well as integration with other activities within the health system and those funded by development partners. The literature suggests that a sustainable system has clearly-defined goals around which stakeholders can rally, but this has not been achieved in the systems studied. The study also found that technical resource constraints – affecting system usage, maintenance, upgrades and repairs – may limit EHIS sustainability even if these other pillars were addressed.
Conclusions
The sustainability of EHIS faces many challenges, which could be addressed through systems’ technical design, stakeholder coordination, and the building of organizational capacity to maintain and enhance such systems. All of this requires time and attention, but is likely to enhance long-term outcomes.
Little is known about how well or under what conditions health innovations are sustained and their gains maintained once they are put into practice. Implementation science typically focuses on uptake by early adopters of one healthcare innovation at a time. The later-stage challenges of scaling up and sustaining evidence-supported interventions receive too little attention. This project identifies the challenges associated with sustainability research and generates recommendations for accelerating and strengthening this work.
Methods
A multi-method, multi-stage approach, was used: (1) identifying and recruiting experts in sustainability as participants, (2) conducting research on sustainability using concept mapping, (3) action planning during an intensive working conference of sustainability experts to expand the concept mapping quantitative results, and (4) consolidating results into a set of recommendations for research, methodological advances, and infrastructure building to advance understanding of sustainability. Participants comprised researchers, funders, and leaders in health, mental health, and public health with shared interest in the sustainability of evidence-based health care.
Results
Prompted to identify important issues for sustainability research, participants generated 91 distinct statements, for which a concept mapping process produced 11 conceptually distinct clusters. During the conference, participants built upon the concept mapping clusters to generate recommendations for sustainability research. The recommendations fell into three domains: (1) pursue high priority research questions as a unified agenda on sustainability; (2) advance methods for sustainability research; (3) advance infrastructure to support sustainability research.
Conclusions
Implementation science needs to pursue later-stage translation research questions required for population impact. Priorities include conceptual consistency and operational clarity for measuring sustainability, developing evidence about the value of sustaining interventions over time, identifying correlates of sustainability along with strategies for sustaining evidence-supported interventions, advancing the theoretical base and research designs for sustainability research, and advancing the workforce capacity, research culture, and funding mechanisms for this important work.
Starting in 1999, Concern Worldwide Inc. (Concern) worked with two Bangladeshi municipal health departments to support delivery of maternal and child health preventive services. A mid-term evaluation identified sustainability challenges. Concern relied on systems thinking implicitly to re-prioritize sustainability, but stakeholders also required a method, an explicit set of processes, to guide their decisions and choices during and after the project.
Methods
Concern chose the Sustainability Framework method to generate creative thinking from stakeholders, create a common vision, and monitor progress. The Framework is based on participatory and iterative steps: defining (mapping) the local system and articulating a long-term vision, describing scenarios for achieving the vision, defining the elements of the model, and selecting corresponding indicators, setting and executing an assessment plan,, and repeated stakeholder engagement in analysis and decisions . Formal assessments took place up to 5 years post-project (2009).
Results
Strategic choices for the project were guided by articulating a collective vision for sustainable health, mapping the system of actors required to effect and sustain change, and defining different components of analysis. Municipal authorities oriented health teams toward equity-oriented service delivery efforts, strengthening of the functionality of Ward Health Committees, resource leveraging between municipalities and the Ministry of Health, and mitigation of contextual risks. Regular reference to a vision (and set of metrics (population health, organizational and community capacity) mitigated political factors. Key structures and processes were maintained following elections and political changes. Post-project achievements included the maintenance or improvement 5 years post-project (2009) in 9 of the 11 health indicator gains realized during the project (1999–2004). Some elements of performance and capacity weakened, but reductions in the equity gap achieved during the project were largely maintained post-project.
Conclusions
Sustainability is dynamic and results from local systems processes, which can be strengthened through both implicit and explicit systems thinking steps applied with constancy of purpose.
The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research.
Methods
Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized.
Results
Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.
Conclusions
Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.
HoPE-LVB project is a trans-boundary project covering Kenya and Uganda. Phase I of the project (2011-2014) was implemented by Pathfinder International, in partnership with Ecological Christian Organization in Uganda and OSIENALA (Friends of Lake Victoria) in Kenya using a population, health and environment (PHE) integrated, rights-based approach. The project’s aim was to reduce threats to biodiversity conservation and ecosystem degradation in the Lake Victoria Basin while simultaneously increasing access to contraception and sexual and reproductive health (SRH) services to improve maternal and child health (MCH) within project communities. This workshop brought together 67 participants including health and conservation practitioners, donors, government and community representatives, policymakers, research and learning institutions, and project team members from Kenya and Uganda. The objectives of the meeting were to:
- Demonstrate benefits of applying a cross-sectoral, integrated approach to sustainable development
- Share learning, results and challenges from implementing the pilot phase of the HoPE-LVB project which was focused on developing a scalable model of integrated population health and environment (PHE) interventions
- Expose participants to systematic approaches to scaling up interventions
- Gather recommendations for scaling HoPE-LVBs’s successfully tested interventions by going through a process of developing a scaling up strategy
- Gauge interest and potential commitment to new partners to support expanded implementation of HoPE-LVB’s sustainable development approach
Health Financing and Costs
Aware of the impact of low use of maternal care on the nutritional status of children, Senegal launched, in 2015, the health and nutrition financing project (PFSN) for a period of four years. This project notably combined a component to strengthen the supply of health care through an RBF intervention and a component to strengthen the demand for health care with a conditional cash-transfer intervention .or CCT), sometimes referred to as “FBR-demand” in response to the FBR supporting the supply of care. Through the innovative combination of these two components in sub-Saharan Africa, the NSTP aimed to increase the quantity and improve the quality of the care provided. On the one hand, the establishment of a RBF aimed to respond, as elsewhere, to the low motivation of health workers and, consequently, to one of the reasons explaining the low performance of health human resources whose the effect on the quality of the health services offered is undeniable. And this, even if the debate on the effects of RBF remains lively, in particular due to the heterogeneity of the results observed (Binyaruka et al ., 2020; IOD PARC, 2018; James et al. , 2020; Kovacs et al.., 2020). On the other hand, it was a question of responding with the CCT to the financial obstacle of access to maternal and child health care, since in Senegal health expenses remain in most cases borne by households – and with even greater difficulty by the most vulnerable households. By associating support for the supply and demand for health care, this new project was a credible , albeit partial, response to certain criticisms leveled against the RBF. Indeed, it is often criticized for only aiming to strengthen the supply of care [1] , thus concealing the major difficulties of access, particularly financial, for populations seeking care.
The World Bank could have made this ambitious project, once completed, a reference in the sub-region, a new " best model " a bit more local than the Rwandan example [2] - its favorite African example, to be travel (Falisse, 2019) and to multiply. The promotion of the Senegalese hybrid model would have made it possible, on the one hand, to relaunch the RBF projects in decline in the surrounding countries [3] and, on the other hand, to pursue ever more new RBF projects in West Africa. the West. However, and despite its success story potential, the health and nutrition financing project never really took off. He too, as in Mali or Burkina Faso, remained bogged down in the pilot stage, which very logically reduced to ashes the transformative expectations that had been assigned to him. The RBF component was simply stopped at the end of 2018. In line with the study conducted by Seppey, Ridde and Somé [4] and in view of the scant attention traditionally given to the question of the deployment of RBF programs (Shroff et al., 2017), we seek in this chapter to examine the potential reasons for the failed scaling up of the experience of combining the RBF and CCT components within the framework of the NSTP in Senegal, using the theory of currents of Kingdon (1995), in order to apprehend its stagnation.
Numerous countries have undertaken performance-based financing (PBF) reforms to improve quality and quantity of healthcare services. However, only few reforms have successfully managed to achieve the different scale-up phases. In Burkina Faso, a pilot project was implemented, but was put on hold before being scaled. During the writing of this article, discussions to scale-up were still ongoing on a national strategic purchasing strategy within a government led user fee exemption policy.
Methods
This study’s objective is to identify facilitators and barriers to scaling-up for that pilot, based on the World Health Organization’s (WHO’s) theoretical framework. Interviews were conducted in three health centres and in Ouagadougou to discuss the scale-up with different actors. The software QDA Miner© was used to help in the framework analysis.
Results
The low involvement of some key stakeholders (mainly decision-makers) and the unstable context hindered ownership of the project, thus its priority on the political agenda. PBF reform therefore lost its momentum to the benefit of a user fee exemption policy. This latter program was seen to be more beneficial since it addressed access to healthcare services, in comparison to service quality, which was the PBF’s relative advantage. A scale-up of some PBF elements (eg, strategic purchasing tools) is however still in discussion in 2019, but would be integrated within the user fee exemption program. Increased costs during the PBF’s implementation gave the impression that the project was too costly and not scalable. The involvement of an important funding agency (World Bank, WB) also fed the impression of high costs, which demotivated the actors, especially decision-makers.
Conclusion
Contextual factors remain central to the implementation of PBF, while their evaluation and mitigation have remained unclear. The participation of key actors in scaling-up operations and the use of social science as tools to better understand the context is therefore primordial.
To estimate annual costs of a multifaceted adolescent sexual health intervention in Mwanza, Tanzania, by input (capital and recurrent), component (in-school, community activities, youth-friendly health services, condom distribution), and phase (development, startup, trial implementation, scale-up).
Study Design:
Financial and economic providers’ costs and intervention outputs were collected to estimate annual total and unit costs (1999–2001). The incremental financial budget projects funding requirements for scale-up within an integrated model.
Results:
The 3-year economic costs of trial implementation were $879,032, of which ∼70% were for the school-based component. Costs of initial development and startup were relatively substantial (∼21% of total costs); however, annual costs per school child dropped from $16 in 1999 to $10 in 2001. The incremental scale-up cost is ∼1/5 of ward trial implementation running costs.
Conclusions:
Annual costs can reduce by almost 40% as project implementation matures. When scaled up, only an additional $1.54 is needed per pupil per year to continue the intervention.
Monitoring and Evaluation of Scale Up
Donors are increasingly interested in the transition and sustainability of global health programs as priorities shift and external funding declines. Systematic and high-quality monitoring and evaluation (M&E) of such processes is rare. We propose a framework and related guiding questions to systematize the M&E of global health program transitions.
Methods:
We conducted stakeholder interviews, searched the peer-reviewed and gray literature, gathered feedback from key informants, and reflected on author experiences to build a framework on M&E of transition and to develop guiding questions.
Findings:
The conceptual framework models transition as a process spanning pre-transition and transition itself and extending into sustained services and outcomes. Key transition domains include leadership, financing, programming, and service delivery, and relevant activities that drive the transition in these domains forward include sustaining a supportive policy environment, creating financial sustainability, developing local stakeholder capacity, communicating to all stakeholders, and aligning programs. Ideally transition monitoring would begin prior to transition processes being implemented and continue for some time after transition has been completed. As no set of indicators will be applicable across all types of health program transitions, we instead propose guiding questions and illustrative quantitative and qualitative indicators to be considered and adapted based on the transition domains identified as most important to the particular health program transition. The M&E of transition faces new and unique challenges, requiring measuring constructs to which evaluators may not be accustomed. Many domains hinge on measuring ‘‘intangibles’’ such as the management of relationships. Monitoring these constructs may require a compromise between rigorous data collection and the involvement of key stakeholders.
Conclusion:
Monitoring and evaluating transitions in global health programs can bring conceptual clarity to the transition process, provide a mechanism for accountability, facilitate engagement with local stakeholders, and inform the management of transition through learning. Further investment and stronger methodological work are needed.
Eliminating violence against children is a prominent policy goal, codified in the Sustainable Development Goals, and parenting programs are one approach to preventing and reducing violence. However, we know relatively little about dissemination and scale-up of parenting programs, particularly in low- and middle-income countries (LMICs). The scale-up of two parenting programs, Parenting for Lifelong Health (PLH) for Young Children and PLH for Parents and Teens, developed under Creative Commons licensing and tested in randomized trials, provides a unique opportunity to study their dissemination in 25 LMICs.
Methods
The Scale-Up of Parenting Evaluation Research (SUPER) study uses a range of methods to study the dissemination of these two programs. The study will examine (1) process and extent of dissemination and scale-up, (2) how the programs are implemented and factors associated with variation in implementation, (3) violence against children and family outcomes before and after program implementation, (4) barriers and facilitators to sustained program delivery, and (5) costs and resources needed for implementation. Primary data collection, focused on three case study projects, will include interviews and focus groups with program facilitators, coordinators, funders, and other stakeholders, and a summary of key organizational characteristics. Program reports and budgets will be reviewed as part of relevant contextual information. Secondary data analysis of routine data collected within ongoing implementation and existing research studies will explore family enrollment and attendance, as well as family reports of parenting practices, violence against children, child behavior, and child and caregiver wellbeing before and after program participation. We will also examine data on staff sociodemographic and professional background, and their competent adherence to the program, collected as part of staff training and certification.
Discussion
This project will be the first study of its kind to draw on multiple data sources and methods to examine the dissemination and scale-up of a parenting program across multiple LMIC contexts. While this study reports on the implementation of two specific parenting programs, we anticipate that our findings will be of relevance across the field of parenting, as well as other violence prevention and social programs.
Health - General
Context: Scaling of effective innovations in health and social care is essential to increase their impact. We aimed to synthesize the evidence base on scaling and identify current knowledge gaps.
Methods: We conducted an umbrella review according to the Joanna Briggs Institute Reviewers' Manual. We included any type of review that 1) focused on scaling, 2) covered health or social care, and 3) presented a methods section. We searched MEDLINE (Ovid), Embase, PsycINFO (Ovid), CINAHL (EBSCO), Web of Science, The Cochrane Library, Sociological Abstracts (ProQuest), Academic Search Premier (EBSCO), and ProQuest Dissertations & Theses Global from their inception to August 6, 2020. We searched the gray literature using, e.g., Google and WHO-ExpandNet. We assessed methodological quality with AMSTAR2. Paired reviewers independently selected and extracted eligible reviews and assessed study quality. A narrative synthesis was performed.
Findings: Of 24,269 records, 137 unique reviews were included. The quality of the 58 systematic reviews was critically low (n = 42). The most frequent review type was systematic review (n = 58). Most reported on scaling in low- and middle-income countries (n = 59), whereas most first authors were from high-income countries (n = 114). Most reviews concerned infectious diseases (n = 36) or maternal-child health (n = 28). They mainly focused on interventions (n = 37), barriers and facilitators (n = 29), frameworks (n = 24), scalability (n = 24), and costs (n = 14). The WHO/ExpandNet scaling definition was the definition most frequently used (n = 26). Domains most reported as influencing scaling success were building scaling infrastructure (e.g., creating new service sites) and human resources (e.g., training community health care providers).
Conclusions: The evidence base on scaling is evolving rapidly as reflected by publication trends, the range of focus areas, and diversity of scaling definitions. Our study highlights knowledge gaps around methodology and research infrastructures to facilitate equitable North-South research relationships. Common efforts are needed to ensure scaling expands the impacts of health and social innovations to broader populations.
Keywords: capacity building; delivery of health care; diffusion of innovation; evidence-based practice; health plan implementation; review literature as topic; scalability; scaling science.
Social accountability consists of strategies, approaches, and tools that enable service users to voice their concerns and hold service providers accountable for the quality of the services they are providing. The ability to voice interests and concerns around the services that have a direct effect on an individual or community’s wellbeing and welfare is a significant marker of an engaged citizenry and an informed community.
CARE has a long history of applying social accountability approaches across multiple sectors. However, one of CARE’s most effective tools for social accountability is the Community Score Card© (CSC). Created in 2002 by CARE Malawi, the CSC has contributed to strengthening service provision and community-state relations in the health, food security, water and sanitation, and education sectors. It was developed by CARE Malawi to address local challenges and has been recognized globally as an important tool for accountability and community engagement, as well as improving service quality.
Through this brief, we aim to outline CARE’s history in designing and implementing the CSC. We invite you to read about the innovation of the CSC in Malawi and the evidence generated over nearly two decades of implementation and adaptation. We hope you will join us as partners in further expanding the vision and use of this tool as a means to elevate community voice and improve access to critical services.
Approximately 15% of the world population have some forms of disability and their quality of life is compromised. According to Thailand Persons with Disabilities (PWDs) Empowerment Act, B.E. 2550 (2007), PWDs are entitled for benefits ranging from medical care to social support services. The CBR framework and the International Classification of Functioning, Disability and Health (ICF) can be used to promote the interdisciplinary approach across staff from different organizations. This study aimed to demonstrate the capacity building strategy for user organizations and resource teams, the key components in environment of scale-up as described in “WHO/ExpandNet Scaling-up Framework” to promote the implementation process of CBR interventions in Thailand.
Methods
The study was conducted with a network of representative from five sub-districts in Thailand. A set of capacity building training courses was designed. Fieldworkers were trained to administer the ICF questionnaire to collect data of PWDs in community. A qualitative interview was conducted to investigate the changes of the interdisciplinary teams.
Results
The total of 1,783 PWDs data were collected during 1 April 2018–30 December 2019. All of them have, at least, one type of impairment and one type of difficulty in activity of daily living (ADL). Needs of assistive devices and home modifications were also recognized. Individual ICF profiles can also developed to monitor change of their functioning after receiving services. After the discussions in the qualitative interviews, it is indicated that their perceptions towards work with PWDs were changed. The six steps in capacity building include: dialogue, team building, disability role-play; ICF data collection and analysis; developing individual care plans for PWDs; home and environmental modifications for PWDs; training to promote employment opportunities; and evaluation of the care plan.
Conclusions
The study highlighted the innovative training methodology for building up the capacity of staff to work as a team and to become agents of change to set up a strategic plan for delivering CBR interventions in their own settings.
Family Planning
Design and methods: We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007–2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned.
Results: Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners.
Conclusions: IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.
Use of depot medroxyprogesterone acetate (DMPA), often known by the brand name Depo-Provera, has increased globally, particularly in multiple low- and middle-income countries (LMICs). As a reproductive health technology that has scaled up in diverse contexts, DMPA is an exemplar product innovation with which to illustrate the utility of the AIDED model for scaling up family health innovations. Methods: We conducted a systematic review of the enabling factors and barriers to scaling up DMPA use in LMICs. We searched 11 electronic databases for academic literature published through January 2013 (n = 284 articles), and grey literature from major health organizations. We applied exclusion criteria to identify relevant articles from peer-reviewed (n = 10) and grey literature (n = 9), extracting data on scale up of DMPA in 13 countries. We then mapped the resulting factors to the five AIDED model components: ASSESS, INNOVATE, DEVELOP, ENGAGE, and DEVOLVE.
Results:
The final sample of sources included studies representing variation in geographies and methodologies. We identified 15 enabling factors and 10 barriers to dissemination, diffusion, scale up, and/or sustainability of DMPA use. The greatest number of factors were mapped to the ASSESS, DEVELOP, and ENGAGE components.
Conclusions:
Findings offer early empirical support for the AIDED model, and provide insights into scale up of DMPA that may be relevant for other family planning product innovations. Keywords: Scale up, Family health, DMPA, Depo-provera, Low-income settings, Innovation, Global health
Relatively few studies rigorously examine the factors associated with health systems strengthening and scaling of interventions at subnational government levels. We aim to examine how The Challenge Initiative (TCI) coaches subnational (state government) actors to scale proven family planning and adolescent and youth sexual and reproductive health approaches rapidly and sustainably through public health systems to respond to unmet need among the urban poor.
Methods:
This mixed-methods comparative case study draws on 32 semistructured interviews with subnational government leaders and managers, nongovernmental organization leaders, and TCI Nigeria staff, triangulated with project records and government health management information system (HMIS) data. Adapting the Consolidated Framework for Implementation Research (CFIR), we contrast experience across 2 higher-performing states and 1 lower-performing state (identified through HMIS data and selected health systems strengthening criteria from 13 states) to identify modifiable factors linked with successful adoption and implementation of interventions and note lessons for supporting scale-up.
Results:
Informants reported that several TCI strategies overlapping with CFIR were critical to states’ successful adoption and sustainment of interventions, most prominently external champions’ contributions and strengthened state planning and coordination, especially in higher-performing states. Government stakeholders institutionalized new interventions through their annual operational plans. Higher-performing states incorporated mutually reinforcing interventions (including service delivery, demand generation, and advocacy). Although informants generally expressed confidence that newly introduced service delivery interventions would be sustained beyond donor support, they had concerns about government financing of demand-side social and behavior change work.
Conclusion:
As political and managerial factors, even more than technical factors, were most linked with successful adoption and scale-up, these processes and systems should be assessed and prioritized from the start. Government leaders, TCI coaches, and other stakeholders can use these findings to shape similar initiatives to sustainably scale social service interventions.
Post pregnancy family planning includes both postpartum and post-abortion periods. Post pregnancy women remain one of the most vulnerable groups with high unmet need for family planning. This review aimed to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning.
Methods
Electronic bibliographic databases (MEDLINE, PubMed, Scopus, the Cochrane Library, and Global Index Medicus) were searched from inception to October 2022 for primary quantitative, qualitative, and mixed method reports on scaling up post pregnancy family planning. Abstracts, titles, and full-text papers were assessed according to the inclusion criteria to select studies regardless of country, language, publication status, or methodological limitations. Data were extracted and methodological quality assessed using the Mixed Methods Appraisal Tool. The convergent integrated approach and a deductive thematic synthesis were used to identify themes and sub-themes of strategies to scale up post pregnancy family planning. The health system building blocks were used to summarize barriers and facilitators. GRADE-CERQual was used to assess our confidence in the findings.
Results
Twenty-nine reports (published 2005–2022) were included: 19 quantitative, 7 qualitative, and 3 mixed methods. Seven were from high-income countries, and twenty-two from LMIC settings. Sixty percent of studies had an unclear risk of bias. The included reports used either separate or bundled strategies for scaling-up post pregnancy family planning. These included strategies for healthcare infrastructure, policy and regulation, financing, human resource, and people at the point of care. Strategies that target the point of care (women and / or their partners) contributed to 89.66% (26/29) of the reports either independently or as part of a bundle. Point of care strategies increase adoption and coverage of post pregnancy contraceptive methods.
Conclusion
Post pregnancy family planning scaling up strategies, representing a range of styles and settings, were associated with improved post pregnancy contraceptive use. Factors that influence the success of implementing these strategies include issues related to counselling, integration in postnatal or post-abortion care, and religious and social norms.
This paper uses the ExpandNet framework to analyze the process of scaling up access to an innovative, natural, modern family planning method, the Standard Days Method® (SDM), in five countries: the Democratic Republic of the Congo (DRC), Guatemala, India, Mali and Rwanda.
Methods
Findings are assessed at the midpoint of a six-year scale-up project and are based on in-depth interviews about project implementation with headquarters and field staff of the Institute for Reproductive Health of Georgetown University, participant observation through field trips to two countries, and review of country-level monitoring data and project documents.
Results
SDM was substantially institutionalized in policies, norms and guidelines and was made available in numerous service delivery sites over the three-year period, although the extent of expansion varied significantly. Demand creation efforts were more limited. Results on the process of expansion showed that scaling up of SDM required 1) a considerable degree of change in the behavior of method users and in the service delivery system; 2) substantial simplification of the training process and materials; 3) adaptation of promotional strategies related to male involvement, condom use, gender issues and other socio-cultural characteristics of the country; 4) capacity building of the public sector in the provision of family planning, beyond a narrow focus on SDM; and 5) partnering with NGOs and the private sector. Government interest in the method in the five countries was an important factor in explaining the success attained; however, continued professional bias among health providers and decision makers remained a significant obstacle. The dedication and the level of effort of the IRH resource team supporting activities and their close coordination with the government were important factors in explaining the progress made.
Conclusion
The country studies identified three major conclusions that have implications for future scaling up of family planning and other health interventions. These relate to: 1) the importance of systems-based strategies rather than single-focused approaches such as training, 2) the need to strike a balance between working to increase the supply-side vs. strengthening the demand-side, and 3) the central role of the resource team working to expand and institutionalize the innovation
We adapted a management systems theory, the Viable System Model (VSM), which presents 5 essential organizational functions and the relations required between them to improve the viability (performance and institutionalization) of organizational systems. Drawing from the VSM, we developed a process for reviewing the effects of proposed approaches on provider workload, client flow, infrastructure, revisions to guidelines and job descriptions, coordination and management, and information systems. The VSM provided a structure to identify potential displacement of capacity in the health system and mitigate often neglected organizational challenges that compromise institutionalization. The process informed the elimination of approaches with potential for impact but that had deal-breakers to institutionalization, such as increased workload or shifted job descriptions, in the Bangladeshi context. For the selected approaches, consideration of systems elements fostered discussion of expected risks to institutionalization, highlighting needed mitigation efforts and monitoring during implementation.
Sexual and Reproductive Health
The introduction of self-administered injectable contraception presents an opportunity to address the unmet need for family planning. As ministries of health scale up self-administered injectable contraception, there is a scarcity of knowledge on the implementation practices and contextual conditions that help and hinder these efforts. The World Health Organization has launched the “enhancing self-administered family planning through embedded research project” (EASIER) to address this challenge.
Objective:
EASIER’s objectives are to: (1) assess the coverage of self-injectable contraception, and the readiness of health systems to integrate it into the contraceptive method mix; (2) document strategies used to introduce and scale up self-injectable contraception and understand practices that have led to success and challenges; (3) identify the contextual factors that affect the adoption and implementation of self-injectable contraception throughout health systems; (4) understand whether implementation addresses users’ preferences and needs; (5) strengthen collaboration between decision makers, researchers, and implementers; support and build capacity to use evidence.
Methods:
EASIER developed a global protocol that implementation research (IR) teams in Burkina Faso, Ghana, and Kenya adapted into country-level embedded IR projects. In all countries (1) at the national level, IR teams evaluate the policy environment for scaling up by conducting a desk review and in-depth interviews; (2) at the local level, IR teams implement quantitative questionnaires on structural and organizational readiness to integrate self-injection into the method mix; (3) in “case study” localities, IR teams conduct in-depth interviews and focus group discussions with implementers, method users, and community members; and (4) IR teams use participatory action research to elicit stakeholder participation and translate findings into programmatic decisions.
Results:
EASIER has been launched in all 3 countries. Preliminary findings are available from Burkina Faso and Kenya. In Burkina Faso, IR teams identified the need to strengthen health worker training approaches to ensure that family planning providers at primary health care facilities are adequately oriented to depo-medroxyprogesterone acetate subcutaneous (DMPA-SC) and self-injection and capacitated to initiate women to the method. In addition, they report the need for service communication strategies that reach potential users of the method with knowledge about self-injection and how to initiate the practice. In Kenya, the findings illuminate the need for practice guidelines that county health teams can use to coordinate the rollout of self-administered DMPA-SC. In addition, Kenya’s findings underscore the importance of addressing logistical bottlenecks to help avoid stock-outs.
Conclusions:
EASIER presents a strategy to embed IR in contraceptive method introduction and scale-up, address local knowledge needs, devise ways to maximize the impact of new technologies in health systems, and build capacity for using evidence in programmatic decisions. Adaptation and implementation of country-level IR studies will advance the use of IR to strengthen family planning programs.
Virtually all women who have cervical cancer are infected with the human papillomavirus (HPV). Of the 275 000 women who die from cervical cancer every year, 88% live in developing countries. Two vaccines against the HPV have been approved. However, vaccine implementation in low-income countries tends to lag behind implementation in high-income countries by 15 to 20 years.
Approach
In 2011, Rwanda’s Ministry of Health partnered with Merck to offer the Gardasil HPV vaccine to all girls of appropriate age. The Ministry formed a “public–private community partnership” to ensure effective and equitable delivery. Local setting Thanks to a strong national focus on health systems strengthening, more than 90% of all Rwandan infants aged 12–23 months receive all basic immunizations recommended by the World Health Organization.
Relevant changes
In 2011, Rwanda’s HPV vaccination programme achieved 93.23% coverage after the first three-dose course of vaccination among girls in grade six. This was made possible through school-based vaccination and community involvement in identifying girls absent from or not enrolled in school. A nationwide sensitization campaign preceded delivery of the first dose.
Lessons learnt
Through a series of innovative partnerships, Rwanda reduced the historical two-decade gap in vaccine introduction between high- and low-income countries to just five years. High coverage rates were achieved due to a delivery strategy that built on Rwanda’s strong vaccination system and human resources framework. Following the GAVI Alliance’s decision to begin financing HPV vaccination, Rwanda’s example should motivate other countries to explore universal HPV vaccine coverage, although implementation must be tailored to the local context.
Malaysia has been at the forefront of the development and scale up of One-Stop Crisis Centres (OSCC) - an integrated health sector model that provides comprehensive care to women and children experiencing physical, emotional and sexual abuse. This study explored the strengths and challenges faced during the scaling up of the OSCC model to two States in Malaysia in order to identify lessons for supporting successful scale-up.
Methods
In-depth interviews were conducted with health care providers, policy makers and key informants in 7 hospital facilities. This was complemented by a document analysis of hospital records and protocols. Data were coded and analysed using NVivo 7.
Results
The implementation of the OSCC model differed between hospital settings, with practise being influenced by organisational systems and constraints. Health providers generally tried to offer care to abused women, but they are not fully supported within their facility due to lack of training, time constraints, limited allocated budget, or lack of referral system to external support services. Non-specialised hospitals in both States struggled with a scarcity of specialised staff and limited referral options for abused women. Despite these challenges, even in more resource-constrained settings staff who took the initiative found it was possible to adapt to provide some level of OSCC services, such as referring women to local NGOs or community support groups, or training nurses to offer basic counselling.
Conclusions
The national implementation of OSCC provides a potentially important source of support for women experiencing violence. Our findings confirm that pilot interventions for health sector responses to gender based violence can be scaled up only when there is a sound health infrastructure in place – in other words a supportive health system. Furthermore, the successful replication of the OSCC model in other similar settings requires that the model – and the system supporting it – needs to be flexible enough to allow adaptation of the service model to different types of facilities and levels of care, and to available resources and thus better support providers committed to delivering care to abused women.
Methods: We used a two-phased sequential approach to data collection and analysis. In Phase A, we conducted a document and literature review and synthesized data thematically. In Phase B, we conducted interviews with stakeholders who used the SA in the countries of interest. We used a qualitative method triangulation technique to analyze and combine data from both phases to understand how the SA was implemented in each country.
Results: Data from 145 documents and 19 interviews described the SA process and activities in each country. All 15 countries completed Stage 1 activities. The activities of Stage 1 determined activities in subsequent stages and varied across countries. Following Stage 1, some countries focused on reforming policies to improve access to sexual and reproductive health (SRH) services whereas others focused on improving provider-level capacity to enhance SRH service quality and improving community-level SRH education. We identified factors across SEM levels that affected SA implementation, including individual- and community-level perceptions of using the SA and the recommendations that emerged from its use, organizational capacity to conduct SA activities, and how well these activities aligned with the existing political climate. Stakeholders perceived SA implementation to be country-driven and systematic in bringing attention to important SRH issues in their countries.
Conclusion: We identified key success factors for influencing the individual, organization, and system change required for implementing the SA. These include sustaining stakeholder engagement for all SA stages, monitoring and reporting on activities, and leveraging activities and outputs from each SA stage to obtain technical and financial support for subsequent stages. Results may be used to optimize ongoing implementation efforts to improve access to and the quality of SRH services.
Screening tests for cervical cancer are effective in reducing the disease burden. In Thailand, a Pap smear program has been implemented throughout the country for 40 years. In 2008 the Ministry of Public Health (MoPH) unexpectedly decided to scale up the coverage of free cervical cancer screening services, to meet an ambitious target. This study analyzes the processes and factors that drove this policy innovation in the area of cervical cancer control in Thailand.
Methods:
In-depth interviews with key policy actors and review of relevant documents were conducted in 2009. Data analysis was guided by a framework, developed on public policy models and existing literature on scaling-up health care interventions.
Results:
Between 2006 and 2008 international organizations and the vaccine industry advocated the introduction of Human Papillomavirus (HPV) vaccine for the primary prevention of cervical cancer. Meanwhile, a local study suggested that the vaccine was considerably less cost-effective than cervical cancer screening in the Thai context. Then, from August to December 2008, the MoPH carried out a campaign to expand the coverage of its cervical cancer screening program, targeting one million women. The study reveals that several factors were influential in focusing the attention of policymakers on strengthening the screening services. These included the high burden of cervical cancer in Thailand, the launch of the HPV vaccine onto the global and domestic markets, the country’s political instability, and the dissemination of scientific evidence regarding the appropriateness of different options for cervical cancer prevention. Influenced by the country’s political crisis, the MoPH’s campaign was devised in a very short time. In the view of the responsible health officials, the campaign was not successful and indeed, did not achieve its ambitious target.
Conclusion:
The Thai case study suggests that the political crisis was a crucial factor that drew the attention of policymakers to the cervical cancer problem and led the government to adopt a policy of expanding coverage of screening services. At the same time, the instability in the political system impeded the scaling up process, as it constrained the formulation and implementation of the policy in the later phase.
Gender and Social Norms
Adolescent Sexual and Reproductive Health
Several countries have set up youth-friendly-health-services. Relatively little is known about approaches to systematically assess their performance against set standards in terms of quality and coverage and define improvement activities based on the findings. The objective of this paper is to fill this gap and to describe the methods and findings of an external review of youth-friendly-health-services in Moldova and the use of the findings to support further planning.
Background
The Republic of Moldova scaled up youth-friendly-health-services (YFHS) nationwide with the target of setting up at least one youth-friendly-health-centre (YFHC) in each of the 35 districts. Methods We carried out an external review of the YFHS in Moldova using a framework that examined the project’s design, implementation and monitoring, outputs, outcomes and impact. We collected primary data - obtained from health worker and client exit interviews with semi-structured questionnaires, direct observation and focus group discussions - and used secondary data from progress reports, previous studies and surveys and national level data. Results While impressive progress with geographical scale up had taken place, services were not always provided to the required quality and comprehensively in the newly established YFHC, thereby diminishing chances of achieving the desired outcomes and impact. The causes of this were identified, and possible ways of addressing them were proposed.
Discussion
Designating health facilities to be made youth friendly and assigning health workers to manage them can be done fairly quickly, improving performance takes time and effort. Approaches that go beyond training such as collaborative learning and job shadowing may hold the best opportunity to improve the knowledge, understanding and motivation of health workers in the newly designated YFHC to address the problem of poor quality.
Conclusions
The Healthy Generation project was well designed and energetically implemented in line with the plan. It has contributed to tangible improvements in the quality of health service provision, and to their uptake. While progress has been made, considerable work is needed, especially in the newer centres. If the efforts of the Healthy Generation project are stepped up, if weaknesses in its planning and implementation are addressed, if complementary activities to build knowledge, understanding, skills and an enabling environment are carried out, the project can be expected to improve the health and well- being of Moldova’s young people.
- Low birthweight, pre-term birth and severe neonatal conditions are among the risks to newborns.
- Chile, England and Ethiopia show that adolescent pregnancy prevention programmes can succeed at scale
Materials and methods: The institutionalization process was facilitated in 17 local government authorities in Tanzania. Quantitative and qualitative data were gathered and analyzed including time-trend analysis of routine performance data, statistical analysis of two rounds of client exit interviews, and thematic analysis of qualitative research.
Results: The sociodemographic characteristics of adolescent girls reached under government-led implementation were comparable to those reached by A360-led implementation. Intervention productivity decreased under government-led implementation but remained consistent. Adopter method mix shifted slightly toward greater long-acting and reversible contraceptive uptake under a government-led model. Factors that enabled successful institutionalization of Kuwa Mjanja included the presence of youth-supportive policies, the establishment of school clubs which provided sexual and reproductive health education, commitment of government stakeholders, and appreciation of adolescent pregnancy as a problem. Some intervention components were important for program effectiveness but proved difficult to institutionalize, primarily because of resource constraints. Lack of adolescent sexual and reproductive health (ASRH)-focused targets and indicators disincentivized Kuwa Mjanja implementation.
Discussion: There is significant potential in operationalizing user-centered ASRH models within government structures, even in a narrow time frame. A360 saw similar performance under government-led implementation and fidelity to the unique experience that the program was designed to deliver for adolescent girls. However, beginning this process earlier presents greater opportunities, as some aspects of the institutionalization process that are critical to sustained impact, for example, shifting government policy and measurement and mobilizing government resources, require heavy coordination and long-term efforts. Programs pursuing institutionalization in a shorter time frame would benefit from setting realistic expectations. This may include prioritizing a smaller subset of program components that have the greatest impact.
Objectives: The purpose of this manuscript is to assess the contribution of The Challenge Initiative (TCI) Business Unusual model on AYSRH services in the counties of Kilifi and Migori, as well as to examine the institutionalization of high impact interventions (HIIs) within the annual work plan, budget, and systems of the said counties. Additionally, this study aims to analyse the trend in contraceptive uptake among adolescent and young women aged 15 to 24 in Kilifi and Migori counties.
Methods: Migori and Kilifi Counties chose to partner with TCI to implement the Business Unusual model. Interested counties apply for the initiative's support and commit to contributing a portion of the funding needed to adapt and implement high impact interventions (HIIs). Based on the identified gaps, TCI supported the counties to prioritize the HIIs including integrated outreaches, youth fixed days, whole site orientation, youth champions, and youth dialogues. The program was implemented between July 2018 to June 2021 in 60 and 68 public health facilities of Kilifi and Migori Counties, respectively. The county teams identified and selected program implementation team whose key role was to coordinate, review, monitor, mobilize resources and report AYSRH program implementation progress.
Results: The results showed a 60% increase in financial commitments on AYSRH programming from 2018 to 2021 in both counties. The average expenditure for committed funds for Kilifi and Migori Counties was 116% and 41% respectively. As the counties continued to allocate and spend funds on the implementation of HIIs, there was a noticeable increase in contraceptive uptake among the young people aged 15 to 24 who visited health facilities for services. There was a 59% and 28% percentage increase in contraceptive uptake among young people (15–24 years) between 2018 and 2021. The proportion of adolescents amongst those presenting for first ANC clinic dropped from 29.4% in 2017 to 9% in 2021 in Kilifi County and from 32.2% in 2017 to 14% in 2021 in Migori County. Using the TCI's Sisi kwa Sisi coaching model of lead-assist-observe-monitor, 20 master coaches were trained. The master coaches cascaded the training to over 97 coaches. The coaches will continue to build capacity of peers in advocacy for resource mobilization and implementation of HIIs. At least nine of TCI's HIIs have been adopted in Kilifi and Migori County strategies and annual work plans, and there is financial support for their sustainability.
Discussion: The increase in adolescent contraceptive uptake might have been as a result of the system strengthening through self-financing of AYSRH programs, the institutionalization of HIIs, and the coaching. Local governments can invest in and sustain their own AYSRH programs, which will lead to an improvement in adolescent and youth access to contraceptive services and, as a result, a reduction in adolescent pregnancies, maternal mortality, and infant mortality.
There is little evidence from the developing world of the effect of scale-up on model adolescent sexual and reproductive health (ASRH) programmes. In this article, we document the effect of scaling up a school-based intervention (MEMA kwa Vijana) from 62 to 649 schools on the coverage and quality of implementation.
Methods
Observations of 1,111 students\\\' exercise books, 11 ASRH sessions, and 19 peer-assistant role plays were supplemented with interviews with 47 ASRH-trained teachers, to assess the coverage and quality of ASRH sessions in schools.
Results
Despite various modifications, the 10-fold scale-up achieved high coverage. A total of 89% (989) of exercise books contained some MEMA kwa Vijana 2 notes. Teachers were enthusiastic and interacted well with students. Students enjoyed the sessions and scripted role plays strengthened participation. Coverage of the biological topics was higher than the psycho-social sessions. The scale-up was facilitated by the structured nature of the intervention and the examined status of some topics. However, delays in the training, teacher turnover, and a lack of incentive for teaching additional activities were barriers to implementation.
Conclusions
High coverage of participatory school-based reproductive health interventions can be maintained during scale-up. However, this is likely to be associated with significant changes in programme content and delivery. A greater emphasis should be placed on improving teachers\\\' capacity to teach more complex-skills–related activities. Future intervention scale-up should also include an increased level of supervision and may be strengthened by underpinning from national level directives and inclusion of behavioral topics in national examinations.
Maternal, Neonatal, Child Health
Chlorhexidine cord care is an effective intervention to reduce neonatal infection and death in resource constrained settings. The Federal Ministry of Health of Ethiopia adopted chlorhexidine cord care in 2015, with national scale-up in 2017. However, there is lack of evidence on the provision of this important intervention in Ethiopia. In this paper, we report on the coverage and determinants of chlorhexidine cord care for newborns in Ethiopia.
Methods
A standardized Nutrition International Monitoring System (NIMS) survey was conducted from January 01 to Feb 13, 2020 in four regions of Ethiopia (Tigray, Amhara, Oromia, and Southern Nations, Nationalities and Peoples Region [SNNPR]) on sample of 1020 women 0–11 months postpartum selected through a multistage cluster sampling approach. Data were collected using interviewer-administered questionnaires in the local languages through home-to-home visit. Accounting for the sampling design of the study, we analyzed the data using complex data analysis approach. Complex sample multivariable logistic regression was used to identify the determinants of chlorhexidine cord care practice.
Results
Overall, chlorhexidine was reportedly applied to the umbilical cord at some point postpartum among 46.1% (95% confidence interval [CI]: 41.1%– 51.2%) of all newborns. Chlorhexidine cord care started within 24 hours after birth for 34.4% (95% CI: 29.5%– 39.6%) of newborns, though this varied widely across regions: from Oromia (24.4%) to Tigray (60.0%). Among the newborns who received chlorhexidine cord care, 48.3% received it for the recommended seven days or more. Further, neonates whose birth was assisted by skilled birth attendants had more than ten times higher odds of receiving chlorhexidine cord care, relative to those born without a skilled attendant (adjusted odds ratio [AOR]: 10.36, 95% CI: 3.73–28.75). Besides, neonates born to mothers with knowledge of the benefit of chlorhexidine cord care had significantly higher odds of receiving chlorhexidine cord care relative to newborns born to mothers who did not have knowledge of the benefit of chlorhexidine cord care (AOR: 39.03, 95% CI: 21.45–71.04).
Conclusion
A low proportion of newborns receive chlorhexidine cord care in Ethiopia. The practice of chlorhexidine cord care varies widely across regions and is limited mostly to births attended by skilled birth attendants. Efforts must continue to ensure women can reach skilled care at delivery, and to ensure adequate care for newborns who do not yet access skilled delivery.
To describe key methodological aspects of the Multi-Country Evaluation of the Integrated Management of Childhood Illness strategy (MCE-IMCI) and analyze their implications for other public health impact evaluations.
Design:
The MCE-IMCI evaluation designs are based on an impact model that defined expectations in the late 1990s about how IMCI would be implemented at country level and below, and the outcomes and impact it would have on child health and survival. MCE-IMCI studies include: feasibility assessments documenting IMCI implementation in 12 countries; in-depth studies using compatible designs in five countries; and cross-site analyses addressing the effectiveness of specific subsets of IMCI activities. The MCE-IMCI was designed to evaluate the impact of IMCI, and also to see that the findings from the evaluation were taken up through formal feedback sessions at national, sub-national and local levels.
Results:
Issues that arose early in the MCE-IMCI included: (1) defining the scope of the evaluation; (2) selecting study sites and developing research designs; (3) protecting objectivity; and (4) developing an impact model. Issues that arose mid-course included: (5) anticipating and addressing problems with external validity; (6) ensuring an appropriate time frame for the full evaluation cycle; (7) providing feedback on results to policymakers and programme implementers; and (8) modifying site-specific designs in response to early findings about the patterns and pace of programme implementation. Two critical issues could best be addressed only near the close of the evaluation: (9) factors affecting the uptake of evaluation results by policymakers and programme decision makers; and (10) the costs of the evaluation.
Conclusions:
Large-scale effectiveness evaluations present challenges that have not been addressed fully in the methodological literature. Although some of these challenges are context-specific, there are important lessons from the MCE that can inform future designs. Most of the issues described here are not addressed explicitly in research reports or evaluation textbooks. Describing and analyzing these experiences is one way to promote improved impact evaluations of new global health strategies. Evaluation, impact evaluation, effectiveness evaluation, IMCI, child health
The Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality targets cannot be achieved without high quality, equitable coverage of interventions at and around the time of birth. This paper provides an overview of the methodology and findings of a nine paper series of in-depth analyses which focus on the specific challenges to scaling up high-impact interventions and improving quality of care for mothers and newborns around the time of birth, including babies born small and sick.
Methods
The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the ENAP process. Country workshops engaged technical experts to complete a tool designed to synthesise "bottlenecks" hindering the scale up of maternal-newborn intervention packages across seven health system building blocks. We used quantitative and qualitative methods and literature review to analyse the data and present priority actions relevant to different health system building blocks for skilled birth attendance, emergency obstetric care, antenatal corticosteroids (ACS), basic newborn care, kangaroo mother care (KMC), treatment of neonatal infections and inpatient care of small and sick newborns.
Results
The 12 countries included in our analysis account for the majority of global maternal (48%) and newborn (58%) deaths and stillbirths (57%). Our findings confirm previously published results that the interventions with the most perceived bottlenecks are facility-based where rapid emergency care is needed, notably inpatient care of small and sick newborns, ACS, treatment of neonatal infections and KMC. Health systems building blocks with the highest rated bottlenecks varied for different interventions. Attention needs to be paid to the context specific bottlenecks for each intervention to scale up quality care. Crosscutting findings on health information gaps inform two final papers on a roadmap for improvement of coverage data for newborns and indicate the need for leadership for effective audit systems.
Conclusions
Achieving the Sustainable Development Goal targets for ending preventable mortality and provision of universal health coverage will require large-scale approaches to improving quality of care. These analyses inform the development of systematic, targeted approaches to strengthening of health systems, with a focus on overcoming specific bottlenecks for the highest impact interventions.
The aim of the study was to determine the feasibility of improved maternal–neonatal care-seeking and household practices using an approach scalable under Nepal's primary health-care services.
Study Design:
Impact was assessed by pre- and post-intervention surveys of women delivering within the previous 12 months. Each district sample comprised 30 clusters, each with 30 respondents. The intervention consisted primarily of community-based antenatal counseling and dispensing and an early postnatal home visit; most activities were carried out by community-based health volunteers.
Result:
There were notable improvements in most household practice and service utilization indicators, although results regarding care-seeking for danger signs were mixed.
Conclusion:
It is feasible in a Nepal setting to significantly improve utilization of maternal–neonatal services and household practices, using the resources available under the government primary health-care system. This has the potential to significantly reduce neonatal mortality.
Obstetric hemorrhage (OH), which includes hemorrhage from multiple etiologies during pregnancy, childbirth, or postpartum, is the leading cause of maternal mortality and accounts for one-quarter of global maternal deaths. The Non-pneumatic Anti-Shock Garment (NASG) is a first-aid device for obstetric hemorrhage that can be applied for post-partum/post miscarriage and for ectopic pregnancies to buy time for a woman to reach a health care facility for definitive treatment. Despite successful field trials, and endorsement by safe motherhood organizations and the World Health Organization (WHO), scale-up has been slow in some countries. This qualitative study explores contextual factors affecting uptake.
Methods
From March 2013 to April 2013, we conducted 13 key informant interviews across four countries with a large burden of maternal mortality that had achieved varying success in scaling up the NASG: Ethiopia, India, Nigeria, and Zimbabwe. These key informants were health providers or program specialists working with the NASG. We applied a health policy analysis framework to organize the results. The framework has five domains: attributes of the intervention, attributes of the implementers, delivery strategy, attributes of the adopting community, the socio-political context, and the research context.
Results
The interviews from our study found that relevant facilitators for scale-up are the simplicity of the device, local and international champions, well-developed training sessions, recommendations by WHO and the International Federation of Gynecology and Obstetrics, and dissemination of NASG clinical trial results. Barriers to scaling up the NASG included limited health infrastructure, relatively high upfront cost of the NASG, initial resistance by providers and policy makers, lack of in-country champions or policy makers advocating for NASG implementation, inadequate return and exchange programs, and lack of political will.
Conclusions
There was a continuum of uptake ranging in both speed and scale. Ethiopia while not the first country to use the NASG has the most rapid scale-up, followed by Nigeria, then India, and finally Zimbabwe. Increasing the coverage of the NASG will require collaboration with local NASG champions, greater NASG awareness among clinicians and policymakers, as well as stronger political will and advocacy.
Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level.
Objective:
Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program.
Methods:
The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback.
Results:
The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs.
Program coverage is likely to be an important determinant of the effectiveness of community interventions to reduce neonatal mortality. Rigorous examination and documentation of methods to scale-up interventions and measure coverage are scarce, however. To address this knowledge gap, this paper describes the process and measurement of scaling-up coverage of a community mobilisation intervention for maternal, child and neonatal health in rural Bangladesh and critiques this real-life experience in relation to available literature on scaling-up.
Methods
Scale-up activities took place in nine unions in rural Bangladesh. Recruitment and training of those who deliver the intervention, communication and engagement with the community and other stakeholders and active dissemination of intervention activities are described. Process evaluation and population survey data are presented and used to measure coverage and the success of scale-up.
Results
The intervention was scaled-up from 162 women\'s groups to 810, representing a five-fold increase in population coverage. The proportion of women of reproductive age and pregnant women who were engaged in the intervention increased from 9% and 3%, respectively, to 23% and 29%.
Conclusions
Examination and documentation of how scaling-up was successfully initiated, led, managed and monitored in rural Bangladesh provide a deeper knowledge base and valuable lessons. Strong operational capabilities and institutional knowledge of the implementing organisation were critical to the success of scale-up. It was possible to increase community engagement with the intervention without financial incentives and without an increase in managerial staff. Monitoring and feedback systems that allow for periodic programme corrections and continued innovation are central to successful scale-up and require programmatic and operational flexibility.
Public-private partnerships (PPPs) have garnered appeal among governments around the world, making impressive contributions to health resource mobilization and improved health outcomes. Saving Mothers, Giving Life (SMGL), a PPP aimed at reducing maternal deaths, was born out of the need to mobilize new actors, capitalize on diverse strengths, and marshal additional resources. A qualitative study was initiated to examine how the SMGL partnership functioned to achieve mortality reduction goals and foster country ownership and sustainability.
Methods:
We purposively selected 57 individuals from U.S. and global public and private partner organizations engaged in SMGL in Uganda and Zambia for qualitative in-depth interviews. Representative selection was based on participant knowledge of partner activities and engagement with the partnership at various points in time. Of those invited, 46 agreed to participate. Transcripts were double-coded, and discordant codes were resolved by consensus.
Results:
Several recurring themes emerged from our study. Perceived strengths of the partnership included goal alignment; diversity in partner expertise; high-quality monitoring, evaluation, and learning; and strong leadership and country ownership. These strengths helped SMGL achieve its goals in reducing maternal and newborn mortality. However, uncertainty in roles and responsibilities, perceived power inequities between partners, bureaucratic processes, a compressed timeline, and limited representation from ministries of health in the SMGL governance structure were reported impediments.
Conclusion:
While SMGL faced many of the same challenges experienced by other PPPs, local counterparts and the SMGL partners were able to address many of these issues and the partnership was ultimately praised for being a successful model of interagency coordination. Efforts to facilitate country ownership and short-term financial sustainability have been put in place for many elements of the SMGL approach; however, long-term financing is still a challenge for SMGL as well as other global health PPPs. Addressing key impediments outlined in this study may improve long-term sustainability of similar PPPs.
There is still limited knowledge regarding the translation of early child development (ECD) knowledge into effective policies and large‐scale programmes. A variety of frameworks that outline the key steps in scaling up exist, but we argue that taking a complex adaptive systems (CAS) approach assists in understanding the complex, dynamic processes that result in programmes being taken to scale. Objectives The objective of this study is to examine the process of scaling up four major country‐level ECD programmes through the application of a CAS framework.
Methods
Nine key informants with a deep knowledge of how each ECD programme was established and brought to scale were interviewed via Skype or phone by using open‐ended interviews. The interviews were tape recorded and then transcribed verbatim for subsequent coding by using CAS domains. The coding and integration of the results to identify unique and common CAS scaling up features across the case studies involved an iterative process of reaching consensus.
Results
The scaling up of all four programmes behaved as a CAS including as follows: (i) positive feedback loops (five themes) and negative feedback loops (two themes); (ii) scale‐free networks (two themes); (iii) phase transitions (four themes); (iv) path dependence (two themes); and (v) emergent behaviour (six themes). Five additional themes were identified for sustainability, which was repeatedly mentioned as an important consideration when deciding how to scale up programmes.
Conclusions
CAS analysis is likely to improve our understanding of how effective ECD programmes become scaled up. Prospective CAS implementation research is needed to continue advancing the knowledge in the field.
Stronger health systems, with an emphasis on community-based primary health care, are required to help accelerate the pace of ending preventable maternal and child deaths as well as contribute to the achievement of the Sustainable Development Goals (SDGs). The success of the SDGs will require unprecedented coordination across sectors, including partnerships between public, private, and non-governmental organizations (NGOs). To date, little attention has been paid to the distinct ways in which NGOs (both international and local) can partner with existing national government health systems to institutionalize community health strategies.
Discussion
In this paper, we propose a new conceptual framework that depicts three primary pathways through which NGOs can contribute to the institutionalization of community-focused maternal, newborn, and child health (MNCH) strategies to strengthen health systems at the district, national or global level. To illustrate the practical application of these three pathways, we present six illustrative cases from multiple NGOs and discuss the primary drivers of institutional change. In the first pathway, “learning for leverage,” NGOs demonstrate the effectiveness of new innovations that can stimulate changes in the health system through adaptation of research into policy and practice. In the second pathway, “thought leadership,” NGOs disseminate lessons learned to public and private partners through training, information sharing and collaborative learning. In the third pathway, “joint venturing,” NGOs work in partnership with the government health system to demonstrate the efficacy of a project and use their collective voice to help guide decision-makers. In addition to these pathways, we present six key drivers that are critical for successful institutionalization: strategic responsiveness to national health priorities, partnership with policymakers and other stakeholders, community ownership and involvement, monitoring and use of data, diversification of financial resources, and longevity of efforts.
Conclusion
With additional research, we propose that this framework can contribute to program planning and policy making of donors, governments, and the NGO community in the institutionalization of community health strategies.
Nutrition
What this article adds: Community-based management of acute malnutrition (CMAM) was first implemented in Pakistan in 2005 as an externally funded, standalone intervention in response to the Azad Kashmir earthquake, and later in response to subsequent crises in Punjab and Sindh provinces. In 2010 the Government of Pakistan (GoP) developed national CMAM guidelines (updated in 2015), used to guide CMAM programming in priority districts, co-funded by GoP and external partners from 2011 onwards. The programme was delivered through a government health service delivery platform, but was vertical with its own workforce, supply chain and information management system. In October 2018 external partners capitalised on the GoP’s signing of the Astana Declaration on Universal Health Coverage and advocated for inclusion of a package of essential nutrition-sensitive actions (including CMAM) in the public health system. This approach has been accepted by the GoP and the essential nutrition package is being costed to inform resource allocation for stepwise rollout. Plans are being made to develop the capacity of the health work force (including lady health workers – Pakistan’s cadre of community health workers) to deliver services and integrate CMAM supplies and data into the routine supply chain and information systems.
What this article adds: Community-based management of acute malnutrition (CMAM) was first implemented in Pakistan in 2005 as an externally funded, standalone intervention in response to the Azad Kashmir earthquake, and later in response to subsequent crises in Punjab and Sindh provinces. In 2010 the Government of Pakistan (GoP) developed national CMAM guidelines (updated in 2015), used to guide CMAM programming in priority districts, co-funded by GoP and external partners from 2011 onwards. The programme was delivered through a government health service delivery platform, but was vertical with its own workforce, supply chain and information management system. In October 2018 external partners capitalised on the GoP’s signing of the Astana Declaration on Universal Health Coverage and advocated for inclusion of a package of essential nutrition-sensitive actions (including CMAM) in the public health system. This approach has been accepted by the GoP and the essential nutrition package is being costed to inform resource allocation for stepwise rollout. Plans are being made to develop the capacity of the health work force (including lady health workers – Pakistan’s cadre of community health workers) to deliver services and integrate CMAM supplies and data into the routine supply chain and information systems.
What this article adds: Alive &Thrive (A&T) carried out implementation research between 2015 and 2016 on the integration of maternal nutrition into existing large-scale programme platforms in Bangladesh. Results demonstrated significant impacts on the coverage of maternal nutrition services, maternal dietary diversity, the number of iron folic acid (IFA) and calcium supplements consumed and exclusive breast-feeding rates in just one year. Effects were likely due to a carefully designed, context-specific package of maternal nutrition interventions, the high quality and coverage of programme delivery and strong stakeholder engagement. Ongoing A&T technical assistance has helped mainstream maternal nutrition in key Government of Bangladesh (GoB) priority areas. This involved inclusion of maternal nutrition interventions in national strategies and programme guidelines, the development of national capacity building materials and supervision tools, the development of health service delivery standard operation procedures and counselling tools and integration with health information systems and social protection programming. Challenges to integration across nutrition-specific and nutrition-sensitive programmes include high staff workload and staff turnover and data gaps in routine monitoring systems.
This brief has been prepared by the Field Exchange Team to summarise highlights from the edition. We share some of the critical issues identfied by contributors that underpin insufficient attention and action on wasting management in the region, provide a snapshot of opportunities and challenges reflected in articles, and share regionally identified priority actions.
Attention to nutrition during all phases of child and adolescent development is necessary to ensure healthy physical growth and to protect investments made earlier in life. Leveraging school meals programs as platforms to scale-up nutrition interventions is relevant as programs function in nearly every country in the world.
Objective:
The aim of this study was to evaluate the impact of a large-scale school meals program in Ghana on schoolage children’s anthropometry indicators. Methods: A longitudinal cluster randomized control trial was implemented across the 10 regions of Ghana, covering 2869 school-age children (aged 5–15 y). Communities were randomly assigned to 1) control group without intervention or 2) treatment group providing the reformed national school feeding program, providing 1 hot meal/d in public primary schools. Primary outcomes included height-for-age (HAZ) and BMI-for-age (BAZ) z scores. The analysis followed an intention-to-treat approach as per the published protocol for the study population and subgroup analysis by age (i.e., midchildhood for children 5–8 y and early adolescence for children 9–15 y), gender, poverty, and region of residence. We used single-difference ANCOVA with mixed-effect regression models to assess program impacts.
Results:
School meals had no effect on HAZ and BAZ in children aged 5–15 y. However, in per-protocol subgroup analysis, the school feeding intervention improved HAZ in 5- to 8-y-old children (effect size: 0.12 SDs), in girls (effect size: 0.12 SDs)—particularly girls aged 5–8 y living in the northern regions, and in children aged 5–8 y in households living below the poverty line (effect size: 0.22 SDs). There was also evidence that the intervention influenced food allocation and sharing at the household level.
Conclusion:
School meals can provide a platform to scale-up nutrition interventions in the early primary school years, with important benefits accruing for more disadvantaged children.
What this article adds: A combination of a persistently high wasting prevalence, advocacy efforts by United Nations (UN) agencies and development partners and the need to respond to severe and recurrent humanitarian crises catalysed an initial pilot Community-based Management of Acute Malnutrition (CMAM) programme in Nepal in 2009 to test delivery models within existing health services. Ten years later, a sustainable scale up of the integrated management of acute malnutrition (IMAM) has been achieved through a government owned and managed approach enabled by a strong policy framework (embedded within the Multi-sectoral Nutrition Plan), national and devolved governance architecture, commitment and dedicated financing and services integrated within a well-developed community health system. The Ministry of Health and Population (MoHP) now funds 90% of the IMAM programme. Technical and financial assistance from United Nations agencies, bilateral donors and non-governmental organisations (NGOs) have enabled the evolution of the IMAM programme. Owing to its success, IMAM was scaled up to cover 38 of 77 districts across the country with capacitated and skilled government health workers delivering care. Surge capacity to emergencies is embedded as part of emergency preparedness. Ongoing challenges being addressed include the supply chain management of ready to use therapeutic food (RUTF), case identification, treatment coverage (low at 15%) and the management of moderate wasting.
Members of the Agriculture and Rural Development working group of the international Scaling Up community of practice held a virtual meeting to discuss these questions and how scaling-up innovations could help to recover from the current crisis and mitigate future ones.
Maternal nutrition interventions are efficacious in improving birth outcomes. It is important to demonstrate that if delivered in field conditions they produce improvements in health and nutrition. Objective Analyses of scaling-up of five program implemented in several countries. These include micronutrient supplementation, food fortification, food supplements, nutrition education and counseling, and conditional cash transfers (as a platform for delivering interventions). Evidence on impact and cost-effectiveness is assessed, especially on achieving high, equitable, and sustained coverage, and reasons for success or failure
Methods
Systematic review of articles on large-scale programs in several databases. Two separate reviewers carried out independent searches. A separate review of the gray literature was carried out including websites of the most important organizations leading with these programs. With Google Scholar a detailed review of the 100 most frequently cited references on each of the five above topics was conducted.
Results
Food fortification programs: iron and folic acid fortification were less successful than salt iodization initiatives, as the latter attracted more advocacy. Micronutrient supplementation programs: Nicaragua and Nepal achieved good coverage. Key elements of success are antenatal care coverage, ensuring availability of tablets, and improving compliance. Integrated nutrition programs in India, Bangladesh, and Madagascar with food supplementation and/or behavioral change interventions report improved coverage and behaviors, but achievements are below targets. The Mexican conditional cash transfer program provides a good example of use of this platform to deliver maternal nutritional interventions.
Conclusions
Programs differ in complexity, and key elements for success vary with the type of program and the context in which they operate. Special attention must be given to equity, as even with improved overall coverage and impact inequalities may even be increased. Finally, much greater investments are needed in independent monitoring and evaluation.
Keywords
Food fortification, food supplementation, nutrition intervention, programs
STIs, HIV/AIDS
Between 2009–2013 the Bill and Melinda Gates Foundation transitioned its HIV/AIDS prevention initiative in India from being a stand-alone program outside of government, to being fully government funded and implemented. We present an independent prospective evaluation of the transition.
Methods
The evaluation drew upon (1) a structured survey of transition readiness in a sample of 80 targeted HIV prevention programs prior to transition; (2) a structured survey assessing institutionalization of program features in a sample of 70 targeted intervention (TI) programs, one year post-transition; and (3) case studies of 15 TI programs.
Findings
Transition was conducted in 3 rounds. While the 2009 transition round was problematic, subsequent rounds were implemented more smoothly. In the 2011 and 2012 transition rounds, Avahan programs were well prepared for transition with the large majority of TI program staff trained for transition, high alignment with government clinical, financial and managerial norms, and strong government commitment to the program. One year post transition there were significant program changes, but these were largely perceived positively. Notable negative changes were: limited flexibility in program management, delays in funding, commodity stock outs, and community member perceptions of a narrowing in program focus. Service coverage outcomes were sustained at least six months post-transition.
Interpretation
The study suggests that significant investments in transition preparation contributed to a smooth transition and sustained service coverage. Notwithstanding, there were substantive program changes post-transition. Five key lessons for transition design and implementation are identified.
Following confirmation of the effectiveness of voluntary medical male circumcision (VMMC) for HIV prevention, the World Health Organization and the Joint United Nations Programme on HIV/AIDS issued recommendations in 2007. Less than 5 y later, priority countries are at different stages of program scale-up. This paper analyzes the progress towards the scale-up of VMMC programs. It analyzes the adoption of VMMC as an additional HIV prevention strategy and explores the factors may have expedited or hindered the adoption of policies and initial program implementation in priority countries to date.
Methods and Findings
VMMCs performed in priority countries between 2008 and 2010 were recorded and used to classify countries into five adopter categories according to the Diffusion of Innovations framework. The main predictors of VMMC program adoption were determined and factors influencing subsequent scale-up explored. By the end of 2010, over 550,000 VMMCs had been performed, representing approximately 3% of the target coverage level in priority countries. The “early adopter” countries developed national VMMC policies and initiated VMMC program implementation soon after the release of the WHO recommendations. However, based on modeling using the Decision Makers' Program Planning Tool (DMPPT), only Kenya appears to be on track towards achievement of the DMPPT-estimated 80% coverage goal by 2015, having already achieved 61.5% of the DMPPT target. None of the other countries appear to be on track to achieve their targets. Potential predicators of early adoption of male circumcision programs include having a VMMC focal person, establishing a national policy, having an operational strategy, and the establishment of a pilot program.
Conclusions
Early adoption of VMMC policies did not necessarily result in rapid program scale-up. A key lesson is the importance of not only being ready to adopt a new intervention but also ensuring that factors critical to supporting and accelerating scale-up are incorporated into the program. The most successful program had country ownership and sustained leadership to translate research into a national policy and program.
The government of the Kingdom of Swaziland recognizes that it must urgently scale up HIV prevention interventions, such as voluntary medical male circumcision (VMMC). Swaziland has adopted a 2-phase approach to male circumcision scale-up. The catch-up phase prioritizes VMMC services for adolescents and adults, while the sustainability phase involves the establishment of early infant male circumcision (EIMC). Swaziland does not have a modern-day tradition of circumcision, and the VMMC program has met with client demand challenges. However, since the launch of the EIMC program in 2010, Swaziland now leads the Eastern and Southern Africa region in the scale-up of EIMC. Here we review Swaziland’s program and its successes and challenges.
Methods:
From February to May 2014, we collected data while preparing Swaziland’s “Male Circumcision Strategic and Operational Plan for HIV Prevention 2014–2018.” We conducted structured stakeholder focus group discussions and in-depth interviews, and we collected EIMC service delivery data from an implementing partner responsible for VMMC and EIMC service delivery. Data were summarized in consolidated narratives.
Results:
Between 2010 and 2014, trained providers performed more than 5,000 EIMCs in 11 health care facilities in Swaziland, and they reported no moderate or severe adverse events. According to a broad group of EIMC program stakeholders, an EIMC program needs robust support from facility, regional, and national leadership, both within and outside of HIV prevention coordination bodies, to promote institutionalization and ownership. Providers and health care managers in 3 of Swaziland’s 4 regional hospitals suggest that when EIMC is introduced into reproductive, maternal, newborn, and child health platforms, dedicated staff attention can help ensure that EIMC is performed amid competing priorities. Creating informed demand from communities also supports EIMC as a service delivery priority. Formative research shows that EIMC programs should address the fears and anxieties of parents so that they, especially fathers, understand the health benefits of EIMC before the birth of their babies.
Conclusion:
The vast majority of public-sector facilities in Swaziland are led by nurses, and nurses and midwives have borne the brunt of caring for patients with HIV/AIDS in Swaziland. Like prevention of mother-to-child transmission, EIMC provides an opportunity for nurses and midwives to stand at the forefront of HIV prevention efforts. Rapid scale-up of VMMC and EIMC in Swaziland has the potential to avert more than 56,000 HIV infections and save US$370 million in the next 20 years.
In 2011, a decision was made to scale up a pilot innovation involving ‘adherence clubs’ as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation.
Results
Our analysis reveals how a programme initially representing a simple, unitary system in terms of management and clinical governance had evolved into a complex, differentiated care system. An innovation that was assessed as an excellent idea and received political backing, worked well whilst supported on a small scale. However, as scaling up progressed, challenges have emerged at the same time as support has waned. We identified a ‘tipping point’ at which the system was more likely to fail, as vulnerabilities magnified and the capacity for adaptation was exceeded. Yet the study also revealed the impressive capacity that a health system can have for catalysing novel approaches.
Conclusions
We argue that innovation in large-scale, complex programmes in health systems is a continuous process that requires ongoing support and attention to new innovation as challenges emerge. Rapid scaling up is also likely to require recourse to further resources, and a culture of iterative learning to address emerging challenges and mitigate complex system errors. These are necessary steps to the future success of adherence clubs as a cornerstone of differentiated care. Further research is needed to assess the equity and quality outcomes of a differentiated care model and to ensure the inclusive distribution of the benefits to all categories of people living with HIV.
Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda.
Methods
This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13).
Results
Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage.
Conclusion
The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.
Malaria and TB
In 2000, an external review mission of the National Tuberculosis Control Programme of Indonesia identified suboptimal results of TB control activities. This led to a prioritization on human resource capacity building representing a major shift in the approach following the recommendations of the external review team.
Case description:
The National Tuberculosis Control Programme (NTP) used a systematic process to develop and implement two strategic action plans focussing on competence development based on specific job descriptions. The approach was a change from only focussing on training, to a broader, long term approach to human resource development for comprehensive TB control. A structured plan for capacity building, including standardized competency based training modules and curricula, was developed in the first phase. This was supported by an organisational system comprised of a training focal point, master trainers, and regional training centres in which nationwide training of supervisors was implemented. Training was expanded to the health service delivery level in the second phase, as well as broadened in the scope of activities beyond training to also include other aspects of human resource development.
Discussion and evaluation:
The result was improved technical and managerial capacity of health workers for TB control at all levels. The impact on case detection and treatment outcome was spectacular, with major improvements in quality of all aspects of service delivery. Conclusion: The strategic decision by the NTP in 2000 to put the highest priority on capacity building has resulted in impressive progress towards TB control targets, a progress that despite many challenges has been sustained.
Brief behavioural support can effectively help tuberculosis (TB) patients quit smoking and improve their outcomes. In collaboration with TB programmes in Bangladesh, Nepal and Pakistan, we evaluated the implementation and scale-up of cessation support using four strategies: (1) brief tobacco cessation intervention, (2) integration of tobacco cessation within routine training, (3) inclusion of tobacco indicators in routine records and (4) embedding research within TB programmes.
Methods
We used mixed methods of observation, interviews, questionnaires and routine data. We aimed to understand the extent and facilitators of vertical scale-up (institutionalization) within 59 health facility learning sites in Pakistan, 18 in Nepal and 15 in Bangladesh, and horizontal scale-up (increased coverage beyond learning sites). We observed training and surveyed all 169 TB health workers who were trained, in order to measure changes in their confidence in delivering cessation support. Routine TB data from the learning sites were analysed to assess intervention delivery and use of TB forms revised to report smoking status and cessation support provided. A purposive sample of TB health workers, managers and policy-makers were interviewed (Bangladesh n = 12; Nepal n = 13; Pakistan n = 19). Costs of scale-up were estimated using activity-based cost analysis.
Results
Routine data indicated that health workers in learning sites asked all TB patients about tobacco use and offered them cessation support. Qualitative data showed use of intervention materials, often with adaptation and partial implementation in busy clinics. Short (1–2 hours) training integrated within existing programmes increased mean confidence in delivering cessation support by 17% (95% CI: 14–20%). A focus on health system changes (reporting, training, supervision) facilitated vertical scale-up. Dissemination of materials beyond learning sites and changes to national reporting forms and training indicated a degree of horizontal scale-up. Embedding research within TB health systems was crucial for horizontal scale-up and required the dynamic use of tactics including alliance-building, engagement in the wider policy process, use of insider researchers and a deep understanding of health system actors and processes.
Conclusions
System-level changes within TB programmes may facilitate routine delivery of cessation support to TB patients. These strategies are inexpensive, and with concerted efforts from TB programmes and donors, tobacco cessation can be institutionalized at scale.
Senegal’s National Malaria Control Programme (NMCP) implements control interventions in the form of targeted packages: (1) scale-up for impact (SUFI), which includes bed nets, intermittent preventive treatment in pregnancy, rapid diagnostic tests, and artemisinin combination therapy; (2) SUFI + reactive case investigation (focal test and treat); (3) SUFI + indoor residual spraying (IRS); (4) SUFI + seasonal malaria chemoprophylaxis (SMC); and, (5) SUFI + SMC + IRS. This study estimates the cost effectiveness of each of these packages to provide the NMCP with data for improving allocative efficiency and programmatic decision-making.
Methods
This study is a retrospective analysis for the period 2013–2014 covering all 76 Senegal districts. The yearly implementation cost for each intervention was estimated and the information was aggregated into a package cost for all covered districts. The change in the burden of malaria associated with each package was estimated using the number of disability adjusted life-years (DALYs) averted. The cost effectiveness (cost per DALY averted) was then calculated for each package.
Results
The cost per DALY averted ranged from $76 to $1591 across packages. Using World Health Organization standards, 4 of the 5 packages were “very cost effective” (less than Senegal’s GDP per capita). Relative to the 2 other packages implemented in malaria control districts, the SUFI + SMC package was the most cost-effective package at $76 per DALY averted. SMC seems to make IRS more cost effective: $582 per DALY averted for SUFI + IRS compared with $272 for the SUFI + IRS + SMC package. The SUFI + focal test and treat, implemented in malaria elimination districts, had a cost per DALY averted of $1591 and was only “cost-effective” (less than three times Senegal’s per capita GDP).
Conclusion
Senegal’s choice of deploying malaria interventions by packages seems to be effectively targeting high burden areas with a wide range of interventions. However, not all districts showed the same level of performance, indicating that efficiency gains are still possible.
In the era of declining development assistance for health, transitioning externally funded programs to governments becomes a priority for donors. However, the process requires a careful approach not only to preserve the public health gains that have already been achieved but also to expand on them. In the Eastern Europe and Central Asia region, countries are expected to graduate from support from the Global Fund to Fight AIDS, Tuberculosis and Malaria in or before 2025. We aim to describe transition risks and identify possible means to address them.
Methods:
Using a theory-based conceptual framework—Transition Preparedness Assessment of Tuberculosis and HIV/AIDS programs—we investigated transition-related challenges through a health systems lens in 10 countries of the Eastern Europe and Central Asia region during 2015–2017. Study findings were derived from systematic collection of quantitative data on socioeconomic indicators and disease epidemics as well as qualitative data from in-depth interviews with 264 stakeholders. These findings were then compared with other donor transition experiences documented elsewhere.
Results:
We found numerous common transition challenges, such as poor monitoring of a country's macroeconomic performance along with weakness in estimating financial needs for successful transition; limited political will of governments to replace donor-funded programs; punitive legislation criminalizing certain behaviors and constraining the government's ability to allocate funds and contract civil society organizations essential to providing services for key populations; limited coordination function of governments and weak decision-making power of coordinating mechanisms obscuring the latter's future role; and inadequate function of national procurement and supply chain management systems undermining an uninterrupted supply of quality-assured drugs and commodities. These challenges are compounded by the risks related to health workforce management leading to specialist shortages and/or inadequately skilled and qualified professionals and by limited funding for critical surveillance activities.
Conclusion:
The complex and multidimensional transition process requires a multipronged approach through well-planned collective and coordinated responses from global, bilateral, and national partners in coming years. Other similar transition processes may provide guidance. Although no “one-size-fits-all” approach exists, previous experiences highlight a need for both early planning and monitoring of the transition along several key dimensions. Issues that could threaten the maintenance of health gains include ongoing stigma against key populations; continued heavy reliance on external funding in some countries, especially for preventive services; the institutional viability of the country coordinating mechanisms; and emerging difficulties with procurement of quality drugs at reasonable prices.
India is considering the scale-up of the Xpert MTB/RIF assay for detection of tuberculosis (TB) and rifampicin resistance. We conducted an economic analysis to estimate the costs of different strategies of Xpert implementation in India.
Methods
Using a decision analytical model, we compared four diagnostic strategies for TB patients: (i) sputum smear microscopy (SSM) only; (ii) Xpert as a replacement for the rapid diagnostic test currently used for SSM-positive patients at risk of drug resistance (i.e. line probe assay (LPA)); (iii) Upfront Xpert testing for patients at risk of drug resistance; and (iv) Xpert as a replacement for SSM for all patients.
Results
The total costs associated with diagnosis for 100,000 presumptive TB cases were: (i) US$ 619,042 for SSM-only; (ii) US$ 575,377 in the LPA replacement scenario; (iii) US$ 720,523 in the SSM replacement scenario; and (iv) US$ 1,639,643 in the Xpert-for-all scenario. Total cohort costs, including treatment costs, increased by 46% from the SSM-only to the Xpert-for-all strategy, largely due to the costs associated with second-line treatment of a higher number of rifampicin-resistant patients due to increased drug-resistant TB (DR-TB) case detection. The diagnostic costs for an estimated 7.64 million presumptive TB patients would comprise (i) 19%, (ii) 17%, (iii) 22% and (iv) 50% of the annual TB control budget. Mean total costs, expressed per DR-TB case initiated on treatment, were lowest in the Xpert-for-all scenario (US$ 11,099).
Conclusions
The Xpert-for-all strategy would result in the greatest increase of TB and DR-TB case detection, but would also have the highest associated costs. The strategy of using Xpert only for patients at risk for DR-TB would be more affordable, but would miss DR-TB cases and the cost per true DR-TB case detected would be higher compared to the Xpert-for-all strategy. As such expanded Xpert strategy would require significant increased TB control budget to ensure that increased case detection is followed by appropriate care.
Intermittent preventive treatment of malaria in pregnancy with 3+ doses of sulfadoxine-pyrimethamine (IPTp-SP) reduces maternal mortality and stillbirths in malaria endemic areas. Between December 2014 and December 2015, a project to scale up IPTp-SP to all pregnant women was implemented in three local government areas (LGA) of Sokoto State, Nigeria. The intervention included community education and mobilization, household distribution of SP, and community health information systems that reminded mothers of upcoming SP doses. Health facility IPTp-SP distribution continued in three intervention (population 661,606) and one counterfactual (population 167,971) LGAs. During the project lifespan, 31,493 pregnant women were eligible for at least one dose of IPTp-SP.
Methods
Community and facility data on IPTp-SP distribution were collected in all four LGAs. Data from a subset of 9427 pregnant women, who were followed through 42 days postpartum, were analysed to assess associations between SP dosages and newborn status. Nominal cost and expense data in 2015 Nigerian Naira were obtained from expenditure records on the distribution of SP.
Results
Eighty-two percent (n = 25,841) of eligible women received one or more doses of IPTp-SP. The SP1 coverage was 95% in the intervention LGAs; 26% in the counterfactual. Measurable SP3+ coverage was 45% in the intervention and 0% in the counterfactual LGAs. The mean number of SP doses in the intervention LGAs was 2.1; 0.4 in the counterfactual. Increased doses of IPTp-SP were associated with linear increases in newborn head circumference and lower odds of stillbirth. Any antenatal care utilization predicted larger newborn head circumference and lower odds of stillbirth. The cost of delivering three doses of SP, inclusive of the cost of medicines, was US$0.93–$1.20.
Conclusions
It is feasible, safe, and affordable to scale up the delivery of high impact IPTp-SP interventions in low resource malaria endemic settings, where few women access facility-based maternal health services.
To evaluate the relative cost-effectiveness of introducing the RTS,S malaria vaccine in sub-Saharan Africa compared with further scale-up of existing interventions.
Design
A mathematical modelling and cost-effectiveness study. Setting Sub-Saharan Africa. Participants People of all ages. Interventions The analysis considers the introduction and scale-up of the RTS,S malaria vaccine and the scale-up of long-lasting insecticide-treated bed nets (LLINs), indoor residual spraying (IRS) and seasonal malaria chemoprevention (SMC). Main outcome measure The number of Plasmodium falciparum cases averted in all age groups over a 10-year period.
Results
Assuming access to treatment remains constant, increasing coverage of LLINs was consistently the most cost-effective intervention across a range of transmission settings and was found to occur early in the cost-effectiveness scale-up pathway. IRS, RTS,S and SMC entered the cost-effective pathway once LLIN coverage had been maximised. If non-linear production functions are included to capture the cost of reaching very high coverage, the resulting pathways become more complex and result in selection of multiple interventions.
Conclusions
RTS,S was consistently implemented later in the cost-effectiveness pathway than the LLINs, IRS and SMC but was still of value as a fourth intervention in many settings to reduce burden to the levels set out in the international goals.
Primary Health Care
In 2013, the Canadian Institutes of Health Research funded 12 community-based primary health care research teams to develop evidence-based innovations. We aimed to explore the scalability of these innovations.
Methods:
In this cross-sectional study, we invited the 12 teams to rate their evidence-based innovations for scalability. Based on a systematic review, we developed a self-administered questionnaire with 16 scalability assessment criteria grouped into 5 dimensions (theory, impact, coverage, setting and cost). Teams completed a questionnaire for each of their innovations. We analyzed the data using simple frequency counts and hierarchical cluster analysis. We calculated the mean number and standard deviation (SD) of innovations that met criteria within each dimension that included more than 1 criterion. The analysis unit was the innovation.
Results:
The 11 responding teams evaluated 33 evidence-based innovations (median 3, range 1–8 per team). The innovations focused on access to care and chronic disease prevention and management, and varied from health interventions to methodological innovations. Most of the innovations were health interventions (n = 21), followed by analytical methods (n = 4), conceptual frameworks (n = 4), measures (n = 3) and strategies to build research capacity (n = 1). Most (29) met criteria in the theory dimension, followed by impact (mean 22.3 [SD 5.6] innovations per dimension), setting (mean 21.7 [SD 8.5]), cost (mean 17.5 [SD 2.1]) and coverage (mean 14.0 [SD 4.1]). On average, the innovations met 10 of the 16 criteria. Adoption was the least assessed criterion (n = 9). Most (20) of the innovations were highly ranked for scalability.
Interpretation:
Scalability varied among innovations, which suggests that readiness for scale up was suboptimal for some innovations. Coverage remained largely unaddressed; further investigation of this critical dimension is necessary.
While an extensive array of existing evidence-based practices (EBPs) have the potential to improve patient outcomes, little is known about how to implement EBPs on a larger scale. Therefore, we sought to identify effective strategies for scaling up EBPs in primary care.
Methods
We conducted a systematic review with the following inclusion criteria: (i) study design: randomized and non-randomized controlled trials, before-and-after (with/without control), and interrupted time series; (ii) participants: primary care-related units (e.g., clinical sites, patients); (iii) intervention: any strategy used to scale up an EBP; (iv) comparator: no restrictions; and (v) outcomes: no restrictions. We searched MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and the Cochrane Library from database inception to August 2016 and consulted clinical trial registries and gray literature. Two reviewers independently selected eligible studies, then extracted and analyzed data following the Cochrane methodology. We extracted components of scaling-up strategies and classified them into five categories: infrastructure, policy/regulation, financial, human resources-related, and patient involvement. We extracted scaling-up process outcomes, such as coverage, and provider/patient outcomes. We validated data extraction with study authors.
Results
We included 14 studies. They were published since 2003 and primarily conducted in low-/middle-income countries (n = 11). Most were funded by governmental organizations (n = 8). The clinical area most represented was infectious diseases (HIV, tuberculosis, and malaria, n = 8), followed by newborn/child care (n = 4), depression (n = 1), and preventing seniors’ falls (n = 1). Study designs were mostly before-and-after (without control, n = 8). The most frequently targeted unit of scaling up was the clinical site (n = 11). The component of a scaling-up strategy most frequently mentioned was human resource-related (n = 12). All studies reported patient/provider outcomes. Three studies reported scaling-up coverage, but no study quantitatively reported achieving a coverage of 80% in combination with a favorable impact.
Conclusions
We found few studies assessing strategies for scaling up EBPs in primary care settings. It is uncertain whether any strategies were effective as most studies focused more on patient/provider outcomes and less on scaling-up process outcomes. Minimal consensus on the metrics of scaling up are needed for assessing the scaling up of EBPs in primary care.
Canadian health funding currently prioritizes scaling up for evidence-based primary care innovations, but not all teams prepare for scaling up. We explored scalability assessment among primary care innovators in the province of Quebec to evaluate their preparedness for scaling up.
Methods:
We performed a cross-sectional survey from Feb. 18 to Mar. 18, 2019. Eligible participants were 33 innovation teams selected for the 2019 Quebec College of Family Physicians’ Symposium on Innovations. We conducted a Web-based survey in 2 sections: innovation characteristics and the Innovation Scalability Self-administered Questionnaire. The latter includes 16 criteria (scalability components) grouped into 5 dimensions: theory (1 criterion), impact (6 criteria), coverage (4 criteria), setting (3 criteria) and cost (2 criteria). We classified innovation types using the International Classification of Health Interventions. We performed a descriptive analysis using frequency counts and percentages.
Results:
Out of 33 teams, 24 participated (72.7%), with 1 innovation each. The types of innovation were management (15/24), prevention (8/24) and therapeutic (1/24). Most management innovations focused on patient navigation (9/15). In order of frequency, teams had assessed theory (79.2%) and impact (79.2%) criteria, followed by cost (77.1%), setting (59.7%) and coverage (54.2%). Most innovations (16/24) had assessed 10 criteria or more, including 10 management innovations, 5 prevention innovations and 1 therapeutic innovation. Implementation fidelity was the least assessed criterion (6/24).
Interpretation:
The scalability assessments of a primary care innovation varied according to its type. Management innovations, which were the most prevalent and assessed the most scalability components, appear to be most prepared for primary care scale-up in Canada.
Community Health and Community Health Workers
With technical support from the Evidence to Action (E2A) Project and Pathfinder International Nigeria, Cross River State (CRS) operationalized the National Family Planning (FP) Task-Shifting, Task-Sharing (TSTS) Policy through the Saving Mothers, Giving Life (SMGL) Initiative.
Through SMGL, Pathfinder and E2A trained community health extension workers (CHEWs) to provide contraceptive implants, conducted operations research to assess the feasibility of task-shifting the provision of implants to the community level in CRS and Kaduna state, and provided support to the CRS government to develop and implement a TSTS scale-up strategy. During the scale-up strategy development process, four pillars were identified as essential components of the innovation for the scale-up process: training, community mobilization, supportive supervision, and commodity security. Building on these pillars, since 2017, E2A and Pathfinder Nigeria have provided technical assistance to CRS stakeholders at the state and local government levels to implement the strategy for systematic scale-up of task-sharing family planning services-with a particular focus on implant provision.
Based on the collection of both qualitative and secondary quantitative data, this paper documents the experience of planning and managing the effort to operationalize and scale up the family planning task-sharing/task-shifting policy in Cross River State from 2017 to 2018. The purpose of the report is to provide actionable information on how to improve task-shifting scale-up.
We sought to provide a systematic review of the determinants of success in scaling up and sustaining community health worker (CHW) programs in low- and middle-income countries (LMICs).
Methods.
We searched 11 electronic databases for academic literature published through December 2010 (n = 603 articles). Two independent reviewers applied exclusion criteria to identify articles that provided empirical evidence about the scale-up or sustainability of CHW programs in LMICs, then extracted data from each article by using a standardized form. We analyzed the resulting data for determinants and themes through iterated categorization.
Results.
The final sample of articles (n = 19) present data on CHW programs in 16 countries. We identified 23 enabling factors and 15 barriers to scale-up and sustainability, which were grouped into 3 thematic categories: program design and management, community fit, and integration with the broader environment.
Conclusions.
Scaling up and sustaining CHW programs in LMICs requires effective program design and management, including adequate training, supervision, motivation, and funding; acceptability of the program to the communities served; and securing support for the program from political leaders and other health care providers.
m-Health
The research base recommending the use of mobile phone interventions for health improvement is growing at a rapid pace. The use of mobile phones to deliver health behavior change and maintenance interventions in particular is gaining a robust evidence base across geographies, populations, and health topics. However, research on best practices for successfully scaling mHealth interventions is not keeping pace, despite the availability of frameworks for adapting and scaling health programs.
Methods
m4RH—Mobile for Reproductive Health—is an SMS, or text message-based, health information service that began in two countries and over a period of 7 years has been adapted and scaled to new population groups and new countries. Success can be attributed to following key principles for scaling up health programs, including continuous stakeholder engagement; ongoing monitoring, evaluation, and research including extensive content and usability testing with the target audience; strategic dissemination of results; and use of marketing and sustainability principles for social initiatives. This article investigates how these factors contributed to vertical, horizontal, and global scale-up of the m4RH program.
Results
Vertical scale of m4RH is demonstrated in Tanzania, where the early engagement of stakeholders including the Ministry of Health catalyzed expansion of m4RH content and national-level program reach. Ongoing data collection has provided real-time data for decision-making, information about the user base, and peer-reviewed publications, yielding government endorsement and partner hand-off for sustainability of the m4RH platform. Horizontal scale-up and adaptation of m4RH has occurred through expansion to new populations in Rwanda, Uganda, and Tanzania, where best practices for design and implementation of mHealth programs were followed to ensure the platform meets the needs of target populations. m4RH also has been modified and packaged for global scale-up through licensing and toolkit development, research into new business/distribution models, and serving as the foundation for derivative NGO and quasi-governmental mHealth platforms.
Conclusions
The m4RH platform provides an excellent case study of how to apply best practices to successfully scale up mobile phone interventions for health improvement. Applying principles of scale can inform the successful scale-up, sustainability, and potential impact of mHealth programs across health topics and settings.
Keywords: mHealth, scale-up, text messaging, stakeholders, adaptation
Recently mobile health (mHealth) has been implemented in Kenya to support family planning. Our objectives were to investigate disparities in mobile phone ownership and to examine the associations between exposure to family planning messages through mHealth (stand-alone or combined with other channels such as public forums, informational materials, health workers, social media and political/religious/community leaders’ advocacy) and contraceptive knowledge and use.
Methods
Logistic and Poisson regression models were used to analyze the 2014 Kenya Demographic and Health Survey.
Results
Among 31 059 women, 86.7% had mobile phones and were more likely to have received higher education, have children ≤5 y of age and tended to be wealthier or married. Among 7397 women who were sexually active, owned a mobile phone and received family planning messages through at least one channel, 89.8% had no exposure to mHealth. mHealth alone was limited in improving contraceptive knowledge and use but led to intended outcomes when used together with four other channels compared with other channels only (knowledge: incidence rate ratio 1.084 [95% confidence interval {CI} 1.063–1.106]; use: odds ratio 1.429 [95% CI 1.026–1.989]).
Conclusions
Socio-economic disparities existed in mobile phone ownership, and mHealth alone did not improve contraceptive knowledge and use among Kenyan women. However, mHealth still has potential for family planning when used with existing channels.
Universal Access to Health Care
Development - General
This publication provides 12 recommendations for companies, development partners, investors, research organizations, and other intermediaries to engage in the replication of inclusive business models, helping support businesses to expand, disseminate, and reproduce both models and impact.
Why is replication of eco-inclusive enterprises a promising pathway to achieve a low-carbon economy?
Which ways to replicate low-carbon business models exist and how do SEED Winners engage in replication?
Which barriers do those low-carbon eco-inclusive enterprises face when seeking to replicate?
How can different actors support replication of these types of eco-inclusive enterprises for a low-carbon economy?
What should be the main priorities when supporting replication for a low-carbon economy?
Since the global economic crisis, a harsher economic climate and global commitments to address the problems of global health and poverty have led to increased donor interest to fund effective health innovations that offer value for money. Simultaneously, further aid effectiveness is being sought through encouraging governments in low- and middle-income countries (LMICs) to strengthen their capacity to be self-supporting, rather than donor reliant. In practice, this often means donors fund pilot innovations for three to five years to demonstrate effectiveness and then advocate to the national government to adopt them for scale-up within country-wide health systems. We aim to connect the literature on scaling-up health innovations in LMICs with six key principles of aid effectiveness: country ownership; alignment; harmonisation; transparency and accountability; predictability; and civil society engagement and participation, based on our analysis of interviewees’ accounts of scale-up in such settings.
Methods
We analysed 150 semi-structured qualitative interviews, to explore the factors catalysing and inhibiting the scale-up of maternal and newborn health (MNH) innovations in Ethiopia, northeast Nigeria and the State of Uttar Pradesh, India and identified links with the aid effectiveness principles. Our interviewees were purposively selected for their knowledge of scale-up in these settings, and represented a range of constituencies. We conducted a systematic analysis of the expanded field notes, using a framework approach to code a priori themes and identify emerging themes in NVivo 10.
Results
Our analysis revealed that actions by donors, implementers and recipient governments to promote the scale-up of innovations strongly reflected many of the aid effectiveness principles embraced by well-known international agreements - including the Paris Declaration of Aid Effectiveness. Our findings show variations in the extent to which these six principles have been adopted in what are three diverse geographical settings, raising important implications for scaling health innovations in low- and middle-income countries.
Conclusion
Our findings suggest that if donors, implementers and recipient governments were better able to put these principles into practice, the prospects for scaling externally funded health innovations as part of country health policies and programmes would be enhanced.
Youth
Keywords: University student leadership, sexual and reproductive health, Niger, scaling up
Adolescents in Tanzania require health services that respond to their sexual and reproductive health – and other – needs and are delivered in a friendly and nonjudgemental manner. Systematizing and expanding the reach of quality adolescent friendly health service provision is part of the Tanzanian Ministry of Health and Social Welfare's (MOHSW) multi-component strategy to promote and safeguard the health of adolescents.
Objective
We set out to identify the progress made by the MOHSW in achieving the objective it had set in its National Adolescent Health and Development Strategy: 2002–2006, to systematize and extend the reach of Adolescent Friendly Health Services (AFHS) in the country. Methods We reviewed plans and reports from the MOHSW and journal articles on AFHS. This was supplemented with several of the authors’ experiences of working to make health services in Tanzania adolescent friendly.
Results
The MOHSW identified four key problems with what was being done to make health services adolescent friendly in the country – firstly, it was not fully aware of the various efforts under way; secondly, there was no standardized definition of AFHS; thirdly, it had received reports that the quality of the AFHS being provided by some organizations was poor; and fourthly, only small numbers of adolescents were being reached by the efforts that were under way. The MOHSW responded to these problems by mapping existing services, developing a standardized definition of AFHS, charting out what needed to be done to improve their quality and expand their coverage, and integrating AFHS within wider policy and strategy documents and programmatic measurement instruments. It has also taken important preparatory steps to stimulate and support implementation.
Conclusion
The MOHSW is aware that the focus of the effort must now shift from the national to the regional, council and local levels. The onus is on regional and council health management teams as well as health facility managers to take the steps needed to ensure that all adolescents in the country obtain the sexual and reproductive health (SRH) services they need, delivered in a friendly and non-judgemental manner. But they cannot do this without substantial and ongoing support.
KEYWORDS: Social determinants of health adolescent health sexuality education
Accessibility of sexual and reproductive health (SRH) services in many lower-and-middle-income countries (LMICs) and humanitarian settings remains limited, particularly for young people. Young people facing humanitarian crises are also at higher risk for mental health problems, which can further exacerbate poor SRH outcomes. This review aimed to explore, describe and evaluate SRH interventions for young people in LMIC and humanitarian settings to better understand both SRH and psychosocial components of interventions that demonstrate effectiveness for improving SRH outcomes.
Methods
We conducted a systematic review of studies examining interventions to improve SRH in young people in LMIC and humanitarian settings following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standards for systematic reviews. Peer-reviewed journals and grey literature from January 1, 2000 to December 31, 2018 were included. Two authors performed title, abstract and full-text screening independently. Data was extracted and analyzed using a narrative synthesis approach and the practice-wise clinical coding system.
Results
The search yielded 813 results, of which 55 met inclusion criteria for full-text screening and thematic analysis. Primary SRH outcomes of effective interventions included: contraception and condom use skills, HIV/STI prevention/education, SRH knowledge/education, gender-based violence education and sexual self-efficacy. Common psychosocial intervention components included: assertiveness training, communication skills, and problem-solving.
Conclusions
Findings suggest that several evidence-based SRH interventions may be effective for young people in humanitarian and LMIC settings. Studies that use double blind designs, include fidelity monitoring, and focus on implementation and sustainability are needed to further contribute to this evidence-base.
Teenage pregnancy is an issue of inequality affecting the health, well-being, and life chances of young women, young men, and their children. Consequently, high levels of teenage pregnancy are of concern to an increasing number of developing and developed countries. The UK Labour Government's Teenage Pregnancy Strategy for England was one of the very few examples of a nationally led, locally implemented evidence-based strategy, resourced over a long duration, with an associated reduction of 51% in the under-18 conception rate. This article seeks to identify the lessons applicable to other countries.
Methods
The article focuses on the prevention program. Drawing on the detailed documentation of the 10-year strategy, it analyzes the factors that helped and hindered implementation against the World Health Organization (WHO) ExpandNet Framework. The Framework strives to improve the planning and management of the process of scaling-up of successful pilot programs with a focus on sexual and reproductive health, making it particularly suited for an analysis of England\'s teenage pregnancy strategy.
Results
The development and implementation of the strategy matches the Framework's key attributes for successful planning and scaling up of sexual and reproductive health programs. It also matched the attributes identified by the Centre for Global Development for scaled up approaches to complex public health issues.
Conclusions
Although the strategy was implemented in a high-income country, analysis against the WHO-ExpandNet Framework identifies many lessons which are transferable to low- and medium-income countries seeking to address high teenage pregnancy rates.
Keywords Teenage pregnancy Health strategy England Sexual health WHO-ExpandNet framework Adolescents
Poor sexual and reproductive health outcomes among adolescents aged 10–19 years are indicative of the barriers this group faces in accessing health services and highlights a gap in the availability of appropriate services, including adolescent-friendly contraceptive services (AFCS). The HIV Investment Framework identifies contraceptive services as an entry point for HIV counseling, testing, and treatment, and as a component of HIV prevention. To effectively meet the needs of adolescents, greater understanding of effective scale-up strategies for adolescent-friendly services is needed. Methods: The authors conducted a retrospective analysis of AFCS scale-up experiences in Ethiopia, Ghana, Mozambique, Tanzania, and Vietnam using the ExpandNet/World Health Organization framework for systematic scale-up. The authors analyzed the type of scale (expansion or institutionalization), dissemination and advocacy, organizational process, costs and resource mobilization, and monitoring and evaluation.
Results:
The analysis showed that all programs simultaneously pursued expansion and institutionalization, contributing to sustainable scale-up. Advocacy complemented by intensive capacity building at all levels of the health system contributed to adoption of AFCS in national and district work plans and budgets as well strengthening collection of age-disaggregated data.
Discussion:
To achieve scale-up of AFCS, the authors identified the importance of institutionalization and expansion in tandem for synergy and reinforcement, empowering adolescents to be agents of change and hold government accountable to its commitments, and strengthening health systems to sustain AFCS.
Conclusions:
This article contributes to a growing body of evidence around scale-up of AFCS, which can inform the implementation and sustainable scale-up of HIV and other services for adolescents.
A growing number of middle-income countries are scaling up youth-friendly sexual and reproductive health pilot projects to national level programmes. Yet, there are few case studies on successful national level scale-up of such programmes. Estonia is an excellent example of scale-up of a small grassroots adolescent sexual and reproductive health initiative to a national programme, which most likely contributed to improved adolescent sexual and reproductive health outcomes. This study; 1) documents the scale-up process of the Estonian youth clinic network 1991–2013, and 2) analyses factors that contributed to the successful scale-up. This research provides policy makers and programme managers with new insights to success factors of the scale-up, that can be used to support planning, implementation and scale-up of adolescent sexual and reproductive health programmes in other countries.
Methods
Information on the scale-up process and success factors were collected by conducting a literature review and interviewing key stakeholders. The findings were analysed using the WHO-ExpandNet framework, which provides a step-by-step process approach for design, implementation and assessment of the results of scaling-up health innovations.
Results
The scale-up was divided into two main phases: 1) planning the scale-up strategy 1991–1995 and 2) managing the scaling-up 1996–2013. The planning phase analysed innovation, user organizations (youth clinics), environment and resource team (a national NGO and international assistance). The managing phase examines strategic choices, advocacy, organization, resource mobilization, monitoring and evaluation, strategic planning and management of the scale-up.
Conclusions
The main factors that contributed to the successful scale-up in Estonia were: 1) favourable social and political climate, 2) clear demonstrated need for the adolescent services, 3) a national professional organization that advocated, coordinated and represented the youth clinics, 4) enthusiasm and dedication of personnel, 5) acceptance by user organizations and 6) sustainable funding through the national health insurance system. Finally, the measurement and recognition of the remarkable improvement of adolescent SRH outcomes in Estonia would not have been possible without development of good reporting and monitoring systems, and many studies and international publications.
Little is known about how to implement promising small-scale projects to reduce reproductive ill health and HIV vulnerability in young people on a large scale. This evaluation documents and explains how a partnership between a non-governmental organization (NGO) and local government authorities (LGAs) influenced the LGA-led scale-up of an innovative NGO programme in the wider context of a new national multisectoral AIDS strategy.
Methods:
Four rounds of semi-structured interviews with 82 key informants, 8 group discussions with 49 district trainers and supervisors (DTS), 8 participatory workshops involving 52 DTS, and participant observations of 80% of LGAled and 100% of NGO-led meetings were conducted, to ascertain views on project components, flow of communication and decision-making and amount of time DTS utilized undertaking project activities.
Results:
Despite a successful ten-fold scale-up of intervention activities in three years, full integration into LGA systems did not materialize. LGAs contributed significant human resources but limited finances; the NGO retained control over finances and decision-making and LGAs largely continued to view activities as NGO driven. Embedding of technical assistants (TAs) in the LGAs contributed to capacity building among district implementers, but may paradoxically have hindered project integration, because TAs were unable to effectively transition from an implementing to a facilitating role. Operation of NGO administration and financial mechanisms also hindered integration into district systems.
Conclusions:
Sustainable intervention scale-up requires operational, financial and psychological integration into local government mechanisms. This must include substantial time for district systems to try out implementation with only minimal NGO support and modest output targets. It must therefore go beyond the typical three- to four-year project cycles. Scale-up of NGO pilot projects of this nature also need NGOs to be flexible enough to adapt to local government planning cycles and ongoing evaluation is needed to ensure strategies employed to do so really do achieve full intervention integration.
There is little evidence from the developing world of the effect of scale-up on model adolescent sexual and reproductive health (ASRH) programmes. In this article, we document the effect of scaling up a school-based intervention (MEMA kwa Vijana) from 62 to 649 schools on the coverage and quality of implementation.
Methods
Observations of 1,111 students' exercise books, 11 ASRH sessions, and 19 peer-assistant role plays were supplemented with interviews with 47 ASRH-trained teachers, to assess the coverage and quality of ASRH sessions in schools.
Results
Despite various modifications, the 10-fold scale-up achieved high coverage. A total of 89% (989) of exercise books contained some MEMA kwa Vijana 2 notes. Teachers were enthusiastic and interacted well with students. Students enjoyed the sessions and scripted role plays strengthened participation. Coverage of the biological topics was higher than the psycho-social sessions. The scale-up was facilitated by the structured nature of the intervention and the examined status of some topics. However, delays in the training, teacher turnover, and a lack of incentive for teaching additional activities were barriers to implementation.
Conclusions
High coverage of participatory school-based reproductive health interventions can be maintained during scale-up. However, this is likely to be associated with significant changes in programme content and delivery. A greater emphasis should be placed on improving teachers' capacity to teach more complex-skills–related activities. Future intervention scale-up should also include an increased level of supervision and may be strengthened by underpinning from national level directives and inclusion of behavioral topics in national examinations.
Keywords Adolescents Scaling up School based interventions Sexual and reproductive health
While there are a number of examples of successful small-scale, youth-friendly services interventions aimed at improving reproductive health service provision for young people, these projects are often short term and have low coverage. In order to have a significant, long-term impact, these initiatives must be implemented over a sustained period and on a large scale. We conducted a process evaluation of the 10-fold scale up of an evaluated youth-friendly services intervention in Mwanza Region, Tanzania, in order to identify key facilitating and inhibitory factors from both user and provider perspectives.
Methods
The intervention was scaled up in two training rounds lasting six and 10 months. This process was evaluated through the triangulation of multiple methods: (i) a simulated patient study; (ii) focus group discussions and semi-structured interviews with health workers and trainers; (iii) training observations; and (iv) pre- and post-training questionnaires. These methods were used to compare pre- and post-intervention groups and assess differences between the two training rounds.
Results
Between 2004 and 2007, local government officials trained 429 health workers. The training was well implemented and over time, trainers\' confidence and ability to lead sessions improved. The district-led training significantly improved knowledge relating to HIV/AIDS and puberty (RR ranged from 1.06 to 2.0), attitudes towards condoms, confidentiality and young people\'s right to treatment (RR range: 1.23-1.36). Intervention health units scored higher in the family planning and condom request simulated patient scenarios, but lower in the sexually transmitted infection scenario than the control health units. The scale up faced challenges in the selection and retention of trained health workers and was limited by various contextual factors and structural constraints.
Conclusions
Youth-friendly services interventions can remain well delivered, even after expansion through existing systems. The scaling-up process did affect some aspects of intervention quality, and our research supports others in emphasizing the need to train more staff (both clinical and non-clinical) per facility in order to ensure youth-friendly services delivery. Further research is needed to identify effective strategies to address structural constraints and broader social norms that hampered the scale up.
Education
Objective
To provide a systematic description of the crucial factors that facilitated and hindered the scale up process of the YFHS Model in Colombia.
Methods
A comprehensive literature search on SRH services for young people and national efforts to improve their quality of care in Colombia and neighbouring countries was carried out along with interviews with a selection of key stakeholders. The information gathered was analysed using the World Health Organization-ExpandNet framework (WHO-ExpandNet).
Results/Discussion
In 7 years (2007–2013) of the implementation of the YFHS Model in Colombia more than 800 clinics nationally have been made youth friendly. By 2013, 536 municipalities in 32 departments had YFHS, resulting in coverage of 52 % of municipalities offering YHFS. The analysis using the WHO-ExpandNet framework identified five elements that enabled the scale up process: Clear policies and implementation guidelines on YFHS, clear attributes of the user organization and resource team, establishment and implementation of an inter-sectoral and interagency strategy, identification of and support to stakeholders and advocates of YFHS, and solid monitoring and evaluation. The elements that limited or slowed down the scale up effort were: Insufficient number of health personnel trained in youth health and SRH, a high turnover of health personnel, a decentralized health security system, inadequate supply of financial and human resources, and negative perceptions among community members about providing SRH information and services to young people.
Conclusion
Colombia’s experience shows that for large-scale implementation of youth health programmes, clear policies and implementation guidelines, support from institutional leaders and authorities who become champions of YFHS, continuous training of health personnel, and inclusion of users in the design and monitoring of these services are key.
But is this really accurate? Recent evidence suggests that even after these “adolescent” innovations successfully pass through randomized controlled trials (RCT)—the highest bar for evidence—only a handful ever reach meaningful scale or lead to policy change.
Our own experience during the past five and a half years at STIR Education, which aims to reignite and scale teacher motivation, has led us to question this wisdom. Peer organizations who also have experience in this area—including Landesa, Clinton Health Access Initiative, Mothers2Mothers, and the Department for International Development’s Research on Improving Systems of Education program—have similar concerns.
At STIR, we believe programs are most enduring and effective when they are delivered in partnership with governments from the outset and fully integrated into social systems. In partnership with the Ugandan and Indian governments, we have connected with 75,000 teachers and 2.6 million children in five years. Recently, we’ve been asked by both governments to fully integrate our teacher development model into national and state systems. Through this effort, we can support our government partners to improve learning outcomes for 60 million children during the next five years.
In the literature on policy innovation diffusion, political scientists have paid little attention to how ideas for innovation gain prominence on government agendas. By considering the actions of policy entrepreneurs - political actors who promote policy ideas - we can gain important insights into the process of policy innovation and innovation diffusion.
Hypotheses:
Policy entrepreneurs constitute an identifiable class of political actors. Their presence and actions can significantly raise the probability of legislative consideration and approval of policy innovations.
Methods:
Event history analyses of the determinants of legislative consideration and approval of an idea for education reform - school choice - in the 48 contiguous United States from 1987 through 1992. The data set consists of unique information collected in a mail survey of members of the education policy elite in each state, augmented with published statistics.
Results:
Policy entrepreneurs were identified as advocates of school choice in 26 states. While controlling for rival hypotheses, the presence and actions of policy entrepreneurs were found to raise significantly the probability of legislative consideration and approval of school choice as a policy innovation. These results suggest policy entrepreneurs should be given more attention in the literature on policy innovation diffusion.
Building on the success of African governments in expanding access to primary education, opening the door to quality, relevant secondary education is the next challenge. Now is the time to rethink secondary education systems, to ensure youth have the skills and knowledge they need.
Secondary Education in Africa: Preparing Youth for the Future of Work examines the skills, knowledge, and competencies necessary for the labour market. And offers best practices and recommendations for how secondary education can better prepare youth to succeed.
Since 2014, the Center for Universal Education (CUE) at the Brookings Institution has sought to address the challenges of scaling impact in education through the Millions Learning project, which focuses on how and under what conditions quality education innovations scale. In 2020, Millions Learning joined the Global Partnership for Education’s (GPE) Knowledge and Innovation Exchange (KIX), a joint partnership between GPE and the International Development Research Centre (IDRC), to facilitate a cross-national, multi-team, design-based research and professional support initiative called Research on Scaling the Impact of Innovations in Education (ROSIE). ROSIE brings together researchers and practitioners working in 29 LMICs to study processes of scaling education initiatives and to deepen the impact of their ongoing work. Parallel to this work of learning alongside these scaling researchers and practitioners, we are pursuing a complementary qualitative study on how governments identify, adopt, and support education innovations to scale.
While there are many attempts to address low learning outcomes around the world, many efforts abide by a short-term project mindset, limited funding, and a focus on proof-of-concept pilots. However, small-scale efforts cannot solve the challenges within education systems today. Addressing contemporary educational challenges requires coordinated action among stakeholders, ongoing evidence of impact, and an emphasis on expanding and deepening the impact of any single intervention so it reaches more learners and changes whole systems. In a word, it requires “scaling.”
The term “scaling” represents a range of approaches—from deliberate replication to organic diffusion to integration into national systems—that expand and deepen impact, leading to lasting improvements in people’s lives.
This report examines the scaling journeys of 14 regional and global education initiatives that are attempting to scale within 30 low- and middle-income countries (LMICs). In 2020, the Center for Universal Education (CUE) at the Brookings Institution joined the Global Partnership for Education’s (GPE) Knowledge and Innovation Exchange (KIX)—a joint partnership between GPE and the International Development Research Centre (IDRC)—to facilitate a cross-national, multiteam, design-based research and professional support initiative called Research on Scaling the Impact of Innovations in Education (ROSIE). The goal of this partnership is threefold:
1. To enhance the quality and results of scaling efforts among KIX global and regional projects through participatory action research and conceptual and practical guidance.
2. To generate new evidence around effective strategies for scaling education initiatives through research and analysis of KIX partner projects and through complementary research focusing on key drivers and enabling conditions from a national decisionmaker perspective.
3. To develop and disseminate practical, evidence-based resources and conceptual tools for KIX partners, education stakeholders in GPE member countries, regional entities, and the international development community on scaling education initiatives to optimize quality, inclusion, equity, and sustainability.
To pursue this, CUE has been reflecting on what can currently be learned from the 14 ROSIE collaboration teams in order to offer insights and recommendations both for the ROSIE collaborator teams and for other practitioners, policymakers, and funders around the world working to scale the impact of their efforts to improve education and learning outcomes.
The report presents our empirical reflections and offers relevant guidance. Given that the research is ongoing, the report does not offer an overarching explanation of, or framework for, scaling but rather presents illustrative examples and provisional analyses of topics that constitute part of the scaling process in education globally.
In recognition of the importance of financial literacy for young people, Jordan established the National Financial Education Program (FEP) as a core pillar of its National Financial Inclusion Strategy. The FEP offers a full curriculum dedicated to financial literacy that is designed to be interactive, engaging, and relevant to students’ daily lives. Since 2014, the Ministry of Education (MoE), the Jordanian nonprofit INJAZ, the Central Bank of Jordan and key partners from the financial and education sectors have been involved in designing, developing, and implementing a phased rollout of the program across the country. Today FEP is a compulsory class for all school students in grades 7-10, and an optional elective for students in grades 11 and 12.
Agriculture and Environment
their research grantees to prove that their results can be scaled to impact upon the livelihoods of a large number of beneficiaries. Recent studies on scaling have brought critical perspectives to the rather technocratic tendencies in the agricultural innovations scaling literature. Drawing on theoretical debates on spatial strategies and practical experience of agricultural innovation scaling in Ethiopia, this paper adds to the current debate on what constitutes scaling and how to overcome critical scaling constraints. The data for the paper came from a qualitative assessment using focus group discussions, key informant interviews, and document analysis on scaling work done in Ethiopia by a USAID-funded research for development project. The paper concludes with four broad lessons for the current understating of agricultural innovation scaling. First, scaling of agricultural innovations requires a balanced focus on technical requirements and associated social dynamics surrounding scaling targets, actors involved and their social relations. Second, appreciating the social dynamics of scaling emphasizes the fact that scaling is more complex than a linear rolling out of innovations towards diffusion. Third, scaling may not be strictly planned; instead, it might be an extension of the innovation generation process that relies heavily on both new and long-term relationships with key partners, trust, and continuous reflection and learning. Fourth, the overall implication of the above three conclusions is that scaling strategies need to be flexible, stepwise, and reflective. Despite the promises of flourishing scaling frameworks, scaling strategies it would appear from the Africa RISING experience that, if real impact is to be achieved, approaches will be required to be flexible enough to manage the social, processual and emergent nature of the practice of scaling.
Senior Scientist and Systems Agronomist at the International Maize and Wheat
Improvement Center (CIMMYT), discussed the implications of scaling on the management of projects and programs, and the role of leadership, local ownership and collaboration. Additionally, useful tools and tips for practitioners were shared in order to reach sustainable change at scale. The webinar also covered the challenges of mainstreaming a scaling agenda and approach systematically into development institutions.
• The Global Evergreening Alliance (GEA) is building on the experience of thousands of small, local, land evergreening/restoration project successes that demonstrate the great potential for sequestering carbon and boosting livelihoods. The key issue is how to massively scale the thousands of small local successes. How can knowledge about local successes be shared? GEA is responding to this need for sharing knowledge on land restoration and developing more effective scaling strategies for a Global Campaign that aims to sequester 20 billion tons of CO2 annually by the year 2050 through evergreening or nature-based storage of carbon. A scaling working group was formed which identified 12 key principles and other information useful for field practitioners, and this group compiled a set of GEA “Guidelines for Scaling up Evergreening”. More information on GEA is here.
• An additional 15 minutes was reserved for a brainstorm on ideas that the ARD WG should pay more attention to. Most discussion took place about understanding tipping points that drive change at scale as well as the integration of climate change and carbon financing into programs for scaling.
This evaluation draws on the previous experiences of the GEF in scaling up to better understand and draw lessons on the processes through which scaling up occurs and the conditions under which it is effectively achieved. The IEO has been tracking scaling up as one indicator of progress towards impact, reporting its prevalence in the GEF portfolio in the overall performance studies. Moreover, recent evaluations contributing to OPS6, such as those on transformational change and GEF's support for legal and regulatory frameworks, note the importance of the scaling up process in achieving larger-scale impact. This is the first evaluation to systematically assess the scaling up process in depth, and the influencing factors and conditions. Using a purposive sampling approach, the evaluation conducted quantitative and qualitative analyses on both successful and less successful cases of GEF support to scaling up. Information was extracted from document reviews, interviews, and field visits to three countries. The evaluation provides lessons for the GEF in future support for scaling up throughout its portfolio, and for the GEF-7 Impact Programs in particular.
In this paper we are using the mainstream understanding of the three main types of upscaling: reaching many (horizontal), enhancing the enabling environment (vertical), and expanding the product or service’s features (functional). Through a review of the general upscaling literature, coupled with focused interviews with weather/climate services experts, we found that there are common barriers to, and enablers for, successful upscaling – many of which apply to the specific case of upscaling climate services. Barriers include problems with leadership (e.g. the absence of a long-term vision and/or strategy for upscaling); limited funding or lack of a business model for the service at scale; issues with the enabling environment for upscaling (e.g. poor policy context, inadequate governance systems); and poor user engagement.
Lessons learned from the literature in the context of upscaling climate services include planning for it as early as possible in the prototyping process; including a monitoring, evaluation and learning approach to inform upscaling progress; taking actions to foster and enhance the enabling environment; and searching for a balance between generic solutions and fit-for-purpose products.
Research, technology and innovation are key ingredients in transformation. It is, however, the way that transformation reframes innovation and the implications of this for public agricultural research organisations, particularly the CGIAR, that are the focus of this study.
A number of recent studies of current and future agriculture and food trends and challenges have argued that component technology and piecemeal innovation will be inadequate to ensure sustainability and that inclusion concerns must be integrated throughout the agriculture and food sectors. The concept of an agri-food system has emerged as a way to understand and work with these interconnected elements. Agri-food system innovation will involve rethinking how research and innovation are deployed to transform the social, economic and environmental performance of the agriculture and food system. Despite the advent of these new ideas, much of the current narrative remains stuck in a productionist and technology-centric perspective determined by linear and component change logics. This contributes to agri-food systems being locked into incremental change that is out of step with transformation ambitions.
The study’s review of current thinking on innovation and the sustainable development agenda argues that this agenda represents a progressive broadening of the problem framing from firm to sector to society and that this broadening challenges the analytical framing of innovation. In particular, the understanding of transformation as the transition to new societal conditions – or new socio-technical regimes, as these are referred to in recent literature – has caused a shift from innovation systems to system innovation as an analytical and policy framing. Innovation systems here refer to a framing concerned with the networks and institutional and policy conditions that enable the development and use of goods and services. In contrast, system innovation refers to a framing concerned with the reconfiguring and realignment of a diverse array of societal elements – social, political, technical, institutional and policy – for the realisation of societal outcomes such as sustainable and inclusive growth. Whereas an innovation systems framing primarily concerns the level of innovation activity, a system innovation framing primarily concerns the direction of innovation activity and its alignment to desired societal functions.
System innovation is apparent in a number of perspectives that have been developed to help understand how path dependencies and system changes can be managed in the energy, transport and manufacturing sectors.
This Scaling Scan of the Africa RISING (AR) program in the Ethiopian Highlands is a product of the light track module of the ILRI I@S framework.
The Africa RISING program's overarching purpose is "to provide pathways out of hunger and poverty for smallholder families through sustainably intensified farming systems that sufficiently improve food, nutrition, and income security, particularly for women and children, and conserve or enhance the natural resource base."
These Sustainable Intensification (SI) innovations include different technologies on feed and forages, field and high-value crops, land and water management, systems intensification, and enabling environments; all these contribute to sustaining the livelihoods of rural households in the Ethiopian Highlands as identified from the AR phase I exploratory and action research activities. The current phase II of AR is an effort for adopting a systematic approach on using the evidence of positive outcomes generated during phase I to engage more development partners towards impact at scale; it is, therefore, considered a scaling phase.
In this second phase, Africa RISING focuses its research on facilitating development efforts and providing capacity support on the implementation of SI technologies by the partners.
The AR program in Ethiopia operated in four woredas (districts) of the four main highland regions: Basona Worena in the Amhara region; Endamehonei in Tigray, Lemo in the Southern Nations, Nationalities, and People's Region (SNNPR), and Sinana in Oromia. In each woreda, the program worked in two kebeles (villages). This Scaling Scan report examines AR using the Scaling Scan approach and tools to assess and monitor the scalability of its objective of scaling the SI technologies in the project sites and beyond.
Four dimensions-- technical, organizational, leadership, and institutional environment-- are explored across five distinct phases of the innovation process, from the emergence of the innovative idea (1991–1996) through scaling phase in 15 countries under a major institutional innovation (2015-mid-2019), the Sweetpotato for Profit and Health Initiative (SPHI).
Systematically gathering evidence of nutritional impact and ability to scale cost-effectively was requisite for obtaining support for further development and diffusion of the crop. Positive findings from a major study coincided with a major change in the institutional environment which placed agriculture and nutrition at the forefront of the development agenda, resulting in an inflection point in both research and diffusion investment. The role of committed leadership during all phases was critical for success, but particularly during the first decade of limited support in a challenging institutional environment. The most critical technical achievement underpinning scaling was moving from 2 to 13 African countries having local breeding programs. Evidence is presented that adapted, well performing varieties which consumers prefer is the foundation for successful scaling to occur. Building a cadre of within country and regional advocates was critical for getting sustained commitment and local buy-in to the concept of biofortification by regional bodies and governments, which in turn built within country ownership and the willingness of donors to invest. The SPHI united diverse organizations under a common vision with a simple metric--- the number of households reached with improved varieties of sweetpotato. Since 2009, 6.2 million households were reached by July 2019 in 15 SSA countries. Much more remains to be done. Advocacy efforts led to the integration of nutritious foods into many national and regional policies, setting the stage for further investment.
This webinar includes:
1. Our main findings, informed by the experience of a multitude of development projects around the world
2. Real-world experience from our research team in Malawi
3. Practical advice on how to think about scaling-up your projects and initiatives for superior results
This publication, Explorations 04, seeks to unpack the concept of scaling and create conceptual clarity by presenting an overview of the terms, frameworks, and models used in relation to scaling. In doing so, we hope to contribute to the understanding of the specific role of PPPs in scaling and to support practitioners in getting to grips with different scaling approaches.
Based on a literature study and interviews with case owners and thought leaders, this publication collects various concepts, frameworks, models, and approaches and presents an overview and synthesis of these. While the cases studied are from the water and agriculture sectors, the concepts and approaches are of wider relevance.
Goals
Scaled-up agricultural technologies and innovations can be a game-changer in food-insecure countries. This conference sought to address the following questions about scale up:
What hinders large scale adoption?
What makes things scalable?
What driving factors are critical for successful scale up? (e.g., markets, capital, policy, behavioral changes)
How can multi-stakeholder partnerships and initiatives facilitate success?
What has worked, what hasn’t, and why?
Who can I connect with at the conference to enhance scale up efforts?
Ultimately, VisionSpring determined that its mission could be more efficiently and effectively achieved in other ways. The organization decided to end all Central American operations, return donor funding, and pursue exciting new scaling pathways. Along the way, it learned that the path to scale involves constant experimentation; preparation for failure is critical; knowing when to pivot relies on tripwires; reaching economies of scale requires investment and time; and scaling depends on the right staffing and skillsets.
This case is relevant for any social enterprise considering ambitious scaling goals; pursuing cross-subsidy revenue models; evolving its guiding metrics; and working to create a culture of innovation and learning.
Water and Sanitation
Keywords Household water treatment Enablers Sustainability Scale-up Point-of-use (POU)
Knowing that its goal was to scale impact, not simply grow its geographic footprint, the organization refined its model and chose to work more deeply in existing partner communities, raising adoption rates from a low of 14 percent to 60 percent, providing 1.8 million Ugandans with access to clean water. Along the way, it learned that scaling is often a non-linear journey; performance management should be right-sized; local context matters; behavior change is difficult and continuous; and critical foundations must be in place prior to scaling.
This case study is relevant for any social enterprise wanting to effectively leverage evidence to reach audacious goals; to pursue financial sustainability through cost efficiency and earned revenue; and to drive behavior change.