Scaling-up Bibliography

The overarching objective of the African Development Bank (AfDB) Group is to spur sustainable economic development and social progress in its regional member countries (RMCs), thus contributing to poverty reduction.

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.

This is the introduction to a series of issue papers for FP/RH program managers that consider the following questions on the subject of scaling up: A question of change: How do we know when we have achieved scale? A question of capacity: What management, technological, and human competencies are necessary to bring programs to scale? A question of strategy: What strategies most effectively produce the desired leap? A question of impact: How should the desired impact be measured? A question of sustainability: How do we maintain the gains of an expanded and comprehensive program? A question of access: What kind of coverage is enough to qualify as “scaled up”? A question of supply and demand: What is being scaled up? A question of cost: How much will it cost to scale up? A question of resources: What resources are needed and how can they be mobilized? A question of timing: When is the right time to scale up? Scaling Up Reproductive Health Programs: What’s New? “Scaling up” has entered the thinking of program managers as one of the important contemporary challenges for reproductive health programs. On the surface, achieving scale has always been a concern, whether the challenge was defined as increasing the number of users of modern methods, overcoming periods of stagnation, meeting unmet need, or improving program performance in areas of demand, access, and quality. The complexity of reproductive health programs with their multiple client groups, priorities, and linkages to the HIV/AIDS epidemic further complicates the strategies and technologies which need to be brought together to expand programs and increase impact. Sociopolitical changes, health sector reforms, and the shifting sands of resource availability—from money to contraceptives—create additional hurdles for program managers. What is new? It can be argued that the scaling up of reproductive health programs has been going on since they became a focus of health sector and social development. In some situations, programs scale up almost by default as they grow to accommodate population increase, even though indicators remain the same. However, the current term “scaling up” suggests a combination of strategies and technologies that are designed to be faster and of greater magnitude than the normal process of program expansion. It is no longer a question of waiting to see what happens and being surprised by changes, but to create purposeful change. When leaders act to scale up programs, they must make the process of expansion more predictable, eliminate the cycles of growth and stagnation, and most important, transform embryonic programs (often comprised of scattered pilot projects with very limited capacity) into large systems offering a variety of services to entire populations. These are the new challenges that differentiate the challenges of today’s scaling up from the challenges of past program.

in 2015 the international community agreed on a set of ambitious sustainable development goals (SDGs) for the global society, to be achieved by 2030. one of the lessons that the implementation of the millennium development goals (mdgs) has highlighted is the importance of a systematic approach to identify and sequence development interventions—policies, programs, and projects—to achieve such goals at a meaningful scale.1 The Chinese approach to development, which consists of identifying a problem and long-term goal, testing alternative solutions, and then implementing those that are promising in a sustained manner, learning and adapting as one proceeds—Deng Xiaoping’s “crossing the river by feeling the stones”—is an approach that holds promise for successful achievement of the Sdgs. Having observed the Chinese way, then World Bank group president james wolfensohn in 2004, together with the Chinese government, convened a major international conference in Shanghai on scaling up successful development interventions, and in 2005 the world bank group (wbg) published the results of the conference, including an assessment of the Chinese approach. (Moreno-Dodson 2005). Some ten years later, the WBG once again is addressing the question of how to support scaling up of successful development interventions, at a time when the challenge and opportunity of scaling up have become a widely recognized issue for many development institutions and experts. (Cooley and linn 2014)

The Women’s Center of Jamaica Foundation’s (WCJF) Programme for Adolescent Mothers)—has supported pregnant girls and adolescent mothers to have uninterrupted access to education and allied services since 1978. This paper analyzes the conception, establishment, scale up and sustainability of the Programme. The Programme evolved from a small, local initiative into a national and international model. Repeat pregnancy has remained under 2% among programme beneficiaries since inception. While the core package of interventions has remained for the past 40 years, some new dimensions have been added, with the most recent one being support for transition to higher education, all of which are aimed at strengthening the impact of the Programme. The achievements of the Programme were propelled prominently by a progressive national policy environment with the support of several non-state actors. The PAM demonstrates the value of sustained cross-sectoral support, spearheaded, or fully supported by the state in providing opportunities for adolescent mothers.

A good understanding of the scaling up process and a framework for analysing scalability is critical for informed decision making. In this paper a six step process is proposed to assess the scalability of an intervention/project. The approach was used to assess the scalability of the electronic voucher systems of Zambia and the Super Seeds Project in Zimbabwe. Estimated scalability indexes for these two projects were 77 and 85 respectively indicating the high potential for scaling up. The numerical score should not be viewed as carrying mathematical precision, because the scoring is based on subjective assessments. Through a validation process it was established that the approach is logically consistent and technically sound .The methodology also allows for a careful and methodological diagnosis of constraints to scaling-up. Key requirements to perform this analysis are a good understanding of the scaling up process in the local setting: effective participation and engagement of the key stakeholders, and external facilitator with no vested interest in the outcome. However mechanical application of the approach or superficial comparison of scalability indexes of different projects is likely to result in misleading conclusions. The model should be tested more broadly to assess its robustness and wider applicability. Acknowledgement : This paper is based on a research project originally commissioned by Vuna, a regional Climate Smart Agriculture Programme (operating from 2015 - 2018), and funded by the British Government s Department for International Development (DFID) as part of the United Kingdom s aid programme. However, the views and recommendations contained in this report are those of the author, and DFID is not responsible for, or bound by the recommendations made.

Australia and the UK are the only two OECD bilateral aid programs that currently involve significant scaling up of expenditure. Yet “scaling up” involves much more than increased expenditure, important as that is. Scaling up also involves new ways of doing business that scale up, and then sustain, development impact. Scaling up therefore does not simply mean doing more of the same, only bigger. An Effective Aid Program for Australia Making a real difference – Delivering Real Results (Australian Government 2011), the Government’s response to the Independent Review of Aid Effectiveness, recognises the importance of greater selectivity and larger average size programs focused on where Australia can make a difference. An increasing aid budget gives Australia the opportunity, and the financial means, to scale up development impact but this will require new approaches. Taking as its starting point the “Taking Activities to Scale” approach developed by the Brookings Institution (Chandy and Linn 2011) this paper captures some key lessons and experiences of other approaches to scaling up currently being discussed in the international literature. It complements the findings of the ODE-led case study of field level experience of scaling: AusAID’s CAVAC program1 in Cambodia. The paper is structured as follows. Chapter two provides definitions of scaling up from the literature, emphasising that scaling up is more to do with scaling up development impact than it is about scaling up expenditure, although the two are clearly linked. Chapter three summarises seven reasons why scaling up is central to any broader discussion about development effectiveness. It includes examples from the literature where scaling up has been successful – and where it has not. Chapter four summarises some of the main analytical frameworks for scaling up, starting with the Brookings model of taking activities to scale. Chapter five summarises some key practical lessons in scaling up from the literature. Chapter six then discusses possible implications for the Australian aid program in the light of that literature review, and the building blocks we have to work with. Chapter seven provides a short conclusion. This is followed by the References section of literature reviewed.

What are the consequences in the recipient countries, when donor countries close down their bilateral aid programmes? Are exit practices consistent with established principles of partnership and mutuality in development co-operation? These are the two main questions under scrutiny in this evaluation initiated in 2005 by four donor countries - Denmark, the Netherlands, Norway and Sweden. The evaluation is based on country studies in Botswana, Eritrea, India, Malawi and South Africa including 14 exit cases involving any one of the four donors. It is a joint donor evaluation, and representatives of the partner countries were consulted in various ways. The evaluation was carried out in 2007/08 by a consortium of ECORYS (the Netherlands) and Chr. Michelsen Institute (Norway). It was guided by a Steering Group with representatives of the four commissioning donors, and Sida acted as lead agency in the management of the evaluation.

This is the third post in a post series about how to shape and navigate pathways to scale in social accountability. In post 1, we explained that scale is a complex change process. We questioned and reorganized how practitioners and the literature view scale — a to-do recommended in a recently published synthesis paper from the Action for Empowerment and Accountability (A4EA) programme. In post 2, we introduced a “resonance” pathway to scale, which has been largely overlooked in theory, but resonates with many practitioners we talk to. In this post, we’ll discuss the theoretical underpinnings of two pathways that are more familiar in the literature: best practice and resistance. We’ll also provide examples to illustrate them.

In our previous post we previewed our forthcoming paper “How do we shape and navigate pathways to social accountability scale? Introducing a middle-level Theory of Change.” We discussed the dilemma of scaling up in the Transparency, Participation, and Accountability (TPA) sector, and particularly, in social accountability. We argued that there is not one but several pathways to scale and that there is no best pathway, only the pathway that best fits with the available opportunities and constraints in any given context. We defined the pathways as: (1) the replication of best practice; (2) leveraging the countervailing power of resistance; and (3) seeking resonance with existing public sector efforts. In the next three posts we’ll illustrate what these pathways look like. This post will focus on the resonance pathway. We’ll briefly discuss some theory and illustrate it with examples from three contexts (Nigeria, Bangladesh, and Moldova). For a discussion of the other two pathways to scale, you’ll have to wait for the next post.

This column identifies the critical success factors at various stages of program replication and provides insights that may be useful to those seeking to take programs to scale. Any entrepreneur with a successful program thinks of enlarging it or “taking it to scale.” This is just as true of public health as of private business. Many public health programs are developed at a community level and effectiveness research is conducted to evaluate them. Once research indicates that a program works in a local setting, interest often develops to expand it. In some cases, the expansion succeeds, but at other times, barriers are encountered and the process of taking the program to scale fails. Research literature on taking a project to scale has been developed, which draws on a range of program experiences, thus leading to the development of various models for the process. This monograph identifies the critical success factors at various stages of program replication and provides insights that may be useful to those seeking to take programs to scale. Previous research and experience on taking programs to scale has identified five phases that should occur sequentially. At each phase of the process, the implementation team must make a conscious decision about the advisability of moving on to the next stage based on the outcome of the previous stage. The five phases, which are discussed in detail below, are preexploration, exploration, installation, initial program implementation, and ongoing program operations. Throughout this phased approach, care must be taken to ensure that replication activities are well thought out and the conditions for successful replication are carefully examined. As a result of this careful examination, a “go-no-go” decision should be made following the exploration phase to avoid proceeding ahead on the basis of “wishful thinking.” Further, this phased approach provides for greater clarity of roles and responsibilities as the process unfolds. Finally, this approach allows for progressive development of relationships that are central to effective partnerships in taking programs to scale. A few examples may help to illustrate this approach.

Foundations and other private funders increasingly seek opportunities to “scale impact” — that is, to extend the benefits of cost-effective interventions to more people, either by expanding these efforts in their current locations or by replicating them in new locations. However, the effect that funders seek to have on vexing social problems, such as entrenched poverty, the educational achievement gap, and health disparities, will not materialize unless they can identify interventions that truly work and then support sustained, high-quality implementation of these interventions as they scale up. There should be a high bar of reliable evidence to justify substantial scale-up because the stakes are high: Many lives will be affected, substantial funding is typically involved, and valuable resources can be wasted if funders back the wrong interventions. Nevertheless, funders often act without sufficient evidence to guide decisions on whether to invest in particular scale-up opportunities, as well as to confirm that the scale-ups that they do support have been successful. This Guide focuses on eight key questions that funders should generally ask during the stages of scaleup to help them direct resources to the right places. It includes references to the extensive, thoughtful work done by others while providing context and recommendations in a format that facilitates funders’ use of this material. The Guide draws primarily on lessons and principles from evaluations of programs to improve educational, employment, health, and other outcomes for individuals, while recognizing that many funders are also interested in scaling other approaches, including, for example, supporting institutions, disseminating best practices that are embedded in programs with multiple elements, and advocating for changes in public policies and systems.2 (The lessons in this Guide are relevant to this broad range of interventions, but the terms “program” or “services” are used throughout for the sake of simplicity.) building the evidence to support scale-up decisions is typically not a one-time event. It is a continuous — and typically multi-step — journey involving a variety of partners: those who help produce the evidence (for example, grantees, third-party evaluators,4 and the agencies that provide relevant data); key public and private decision-makers to whom the evidence must be communicated; and the service providers that scale up evidence-based approaches in a policy environment that is influenced by a range of public officials, advocacy groups, and other constituencies.5 Ideally, an effective evidence-building process will: Tap the potential for collaborative funding among philanthropic organizations, government, and businesses to support ongoing innovation, evidence-building, and phased scale-up of interventions. To achieve this, funders need to be willing to invest in data collection, analysis, and communication of findings.

Background Scaling up complex health interventions to large populations is not a straightforward task. Without intentional, guided efforts to scale up, it can take many years for a new evidence-based intervention to be broadly implemented. For the past decade, researchers and implementers have developed models of scale-up that move beyond earlier paradigms that assumed ideas and practices would successfully spread through a combination of publication, policy, training, and example. Drawing from the previously reported frameworks for scaling up health interventions and our experience in the USA and abroad, we describe a framework for taking health interventions to full scale, and we use two large-scale improvement initiatives in Africa to illustrate the framework in action. We first identified other scale-up approaches for comparison and analysis of common constructs by searching for systematic reviews of scale-up in health care, reviewing those bibliographies, speaking with experts, and reviewing common research databases (PubMed, Google Scholar) for papers in English from peer-reviewed and “gray” sources that discussed models, frameworks, or theories for scale-up from 2000 to 2014. We then analyzed the results of this external review in the context of the models and frameworks developed over the past 20 years by Associates in Process Improvement (API) and the Institute for Healthcare improvement (IHI). Finally, we reflected on two national-scale improvement initiatives that IHI had undertaken in Ghana and South Africa that were testing grounds for early iterations of the framework presented in this paper. Results The framework describes three core components: a sequence of activities that are required to get a program of work to full scale, the mechanisms that are required to facilitate the adoption of interventions, and the underlying factors and support systems required for successful scale-up. The four steps in the sequence include (1) Set-up, which prepares the ground for introduction and testing of the intervention that will be taken to full scale; (2) Develop the Scalable Unit, which is an early testing phase; (3) Test of Scale-up, which then tests the intervention in a variety of settings that are likely to represent different contexts that will be encountered at full scale; and (4) Go to Full Scale, which unfolds rapidly to enable a larger number of sites or divisions to adopt and/or replicate the intervention. Conclusions Our framework echoes, amplifies, and systematizes the three dominant themes that occur to varying extents in a number of existing scale-up frameworks. We call out the crucial importance of defining a scalable unit of organization. If a scalable unit can be defined, and successful results achieved by implementing an intervention in this unit without major addition of resources, it is more likely that the intervention can be fully and rapidly scaled.

In 2013, the president of Rwanda asked us for evaluation results from across the continent that could provide lessons for his country’s policy decisions. One program tested in Kenya jumped out, and the Rwandan government wanted to know whether it would likely work in Rwanda as well. “Sugar Daddies Risk Awareness,” an HIV-prevention program, was remarkably effective in reducing a key means of HIV transmission: sexual relationships between teenage girls and older men. A randomized controlled trial (RCT) found that showing eighth-grade girls and boys a 10-minute video and statistics on the higher rates of HIV among older men dramatically changed behavior: The number of teen girls who became pregnant with an older man within the following 12 months fell by more than 60 percent.1 This study was compelling partly because of its methodology: Random assignment determined which girls received the risk awareness program and which girls continued to receive the standard curriculum. Our government partners could thereby have confidence that the reduction in risky behavior was actually caused by the program. But if they replicated this approach in a new context, could they expect the impact to be similar? Policy makers repeatedly face this generalizability puzzle—whether the results of a specific program generalize to other contexts—and there has been a long-standing debate among policy makers about the appropriate response. But the discussion is often framed by confusing and unhelpful questions, such as: Should policy makers rely on less rigorous evidence from a local context or more rigorous evidence from elsewhere? And must a new experiment always be done locally before a program is scaled up? These questions present false choices. Rigorous impact evaluations are designed not to replace the need for local data but to enhance their value. This complementarity between detailed knowledge of local institutions and global knowledge of common behavioral relationships is fundamental to the philosophy and practice of our work at the Abdul Latif Jameel Poverty Action Lab (J-PAL), a center at the Massachusetts Institute of Technology (founded in 2003) with a network of affiliated professors and professional staff around the world.

Background:
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

This paper reports on a review of whether and how the programs and projects supported by the United Nations Development Program (UNDP) in four countries (Bosnia and Herzegovina, Egypt, Moldova, and Tajikistan) apply a systematic approach to scaling up in pursuit of the Sustainable Development Goals (SDGs). The paper applies an operational framework consisting of six basic questions: (i) Is there a pathway to scale? (ii) What is the problem to be solved, the vision and target of scale? (iii) What ideas, innovations or models are to be scaled up? (iv) How can the enabling conditions (drivers and spaces) be put in place? (v) How about the sequencing of key steps? (vi) Does monitoring and evaluation support learning for scaling up? The paper concludes that many of UNDP’s programs and projects pursue pathways to scale, but that overall a more systematic operational approach along the lines suggested in this paper would be desirable.

We document the development and institutionalization in Zambia of a health innovation for diarrhea treatment aimed at children aged younger than 5 years: a unique oral rehydration salts and zinc (ORSZ) co-pack. Seven recommendations from the World Health Organization/ExpandNet are used retrospectively to analyze and describe the successful scale-up of this innovation from its concept stage, including in-country expansion and policy, institutional, and regulatory changes. The 7 recommendations comprise using a participatory process, tailoring to the country context, designing research to test the innovation, testing the innovation, identifying success factors, and scaling up. The scale-up of co-packaged ORSZ in Zambia is shown to be sustainable. Five years after donor funding ended in 2018, an independent, local manufacturer continues to supply the private and public sectors on a commercially viable basis. Furthermore, national coverage of ORSZ increased from less than 1% in 2012 to 34% in 2018. A key success factor was the continuous facilitation over 8 years (spanning planning, trial, evaluation, and scale-up) by a learning and steering group chaired by the Ministry of Health, open to all and focused on learning transfer and ongoing alignment with other initiatives. Other success factors included a long lead-in of inclusive initial consultation, ideation, and planning with all key stakeholders to build on and mobilize existing resources, knowledge, structures, and systems; alignment with government policy; thorough testing and radical review of the product and its value chain before scale-up, including manufacture, distribution, policy, and regulatory matters; and adoption by the government of a co-packaging strategy to ensure cases of childhood diarrhea are treated with ORSZ. With appropriate local adaptations, this approach to scale-up could be replicated in other low- and middle-income countries as a strategy to increase coverage of ORSZ and potentially other health products.

Community-driven development boasts many islands of production of outputs by different actors on the basis of success, but these have not scaled up to cover entire subsidiarity, lack of adaptation to the local context using countries. Binswanger and Aiyar examine the possible field-tested manuals, and lack of scaling-up logistics. The obstacles to scaling up, and possible solutions. They authors consider ways of reducing economic and fiscal consider the theoretical case for community-driven costs, overcoming hostile institutional barriers, development and case studies of success in both sectoral overcoming problems of co-production, adapting to the and multisectoral programs. Obstacles to scaling up local context with field testing, and providing scaling-up include high economic and fiscal costs, adverse logistics. Detailed annexes and checklists provide a guide institutional barriers, problems associated with the co- to program design, diagnostics, and tools.

Two years ago, we wrote a NextBillion article on why so many promising innovations are so hard to scale to a level where they have a significant impact on the Sustainable Development Goals. We called for a massive break with the linear and technology-driven way of providing solutions for global problems. We proposed some strategies to develop a more systemic and problem-driven approach to scaling successful initiatives, but we also recognized that the widespread application of such approaches was an exception rather than a rule. Since then, we have observed a surge in the use of words like “systems thinking” and “transformation” in the development sector. For example, in our line of work at the International Maize and Wheat Improvement Center (CIMMYT), we speak less of “agriculture” and more of “agri-food systems,” in which production and consumption are connected and limited to our planetary boundaries. In exploring the implications of this new way of thinking, we’ve asked ourselves what “agri-food system change” really involves, and what that means for scaling innovations in a systems context. To help guide this work, we applied an emblematic system thinking tool, the iceberg model, to the case of scaling land restoration practices in Central America. These are practices that curb erosion and improve soil structure and fertility to allow increased farm productivity and improve water and food security. The iceberg model helped us to recognize the systemic root causes of land degradation, and to identify what it takes to restore lands at a large scale. Below, we’ll explore this model and discuss how it has impacted our efforts to support land restoration and improve agri-food systems.

First published in February 2019, this paper responds to a persistent humanitarian challenge: why do good ideas, demonstrated through pilots, fail to reach a scale at which they can maximise value for people affected by crises? The Untangling the Many Paths to Scale paper offers a new scale framework designed with humanitarian innovation in mind, shaped by four key factors: solution value, difficulty, contextual variation, and operational sustainability. Each combination of factors may have its own methodology and scaling journey, offering innovators a broader, more realistic range of options for determining how to take innovations to scale. Recognizing the diversity of pathways to scale allows for a more realistic consideration of resources, skills, and steps involved in scaling. You can find out more information about this resource on the GAHI website and through watching the video below.

Evidence-based psychotherapies (EBPs) are underused in health care settings. Aligning implementation of EBPs with the needs of health care leaders (i.e., operational stakeholders) can potentially accelerate their uptake into routine practice. Operational stakeholders (such as hospital leaders, clinical directors, and national program officers) can influence development and oversight of clinical programs as well as policy directives at local, regional, and national levels. Thus, engaging these stakeholders during the implementation and dissemination of EBPs is critical when targeting wider use in health care settings. This article describes how research–operations partnerships were leveraged to increase implementation of an empirically supported psychotherapy – brief Cognitive Behavioral Therapy (brief CBT) – in Veterans Health Administration (VA) primary care settings. The partnered implementation and dissemination efforts were informed by the empirically derived World Health Organization’s ExpandNet framework. A steering committee was formed and included several VA operational stakeholders who helped align the brief CBT program with the implementation needs of VA primary care settings. During the first 18 months of the project, partnerships facilitated rapid implementation of brief CBT at eight VA facilities, including training of 12 providers who saw 120 patients, in addition to expanded program elements to better support sustainability (e.g., train-the-trainer procedures).

Evidence-based psychotherapies (EBPs) are underused in health care settings. Aligning implementation of EBPs with the needs of health care leaders (i.e., operational stakeholders) can potentially accelerate their uptake into routine practice. Operational stakeholders (such as hospital leaders, clinical directors, and national program officers) can influence development and oversight of clinical programs as well as policy directives at local, regional, and national levels. Thus, engaging these stakeholders during the implementation and dissemination of EBPs is critical when targeting wider use in health care settings. This article describes how research–operations partnerships were leveraged to increase implementation of an empirically supported psychotherapy – brief Cognitive Behavioral Therapy (brief CBT) – in Veterans Health Administration (VA) primary care settings. The partnered implementation and dissemination efforts were informed by the empirically derived World Health Organization’s ExpandNet framework. A steering committee was formed and included several VA operational stakeholders who helped align the brief CBT program with the implementation needs of VA primary care settings. During the first 18 months of the project, partnerships facilitated rapid implementation of brief CBT at eight VA facilities, including training of 12 providers who saw 120 patients, in addition to expanded program elements to better support sustainability (e.g., train-the-trainer procedures).

HOMELESSNESS, illiteracy, chronic unemployment: nonprofits struggle to address society’s most intractable problems. And yet, as Bill Clinton noted, in reviewing schoolreform initiatives during his presidency, “Nearly every problem has been solved by someone, somewhere.” The frustration is that “we can’t seem to replicate [those solutions] anywhere else.”1 With a few exceptions, the nonprofit sector in the United States is comprised of cottage enterprises – thousands upon thousands of programs, each operating in a single neighborhood, in a single city or town. Often, this may be the most appropriate form of organization, but in some – perhaps many – cases, it represents a substantial loss to society overall. Time, funds, and imagination are poured into new programs that at best reinvent the wheel, while the potential of programs that have already proven their effectiveness remains sadly underdeveloped. One impediment to replication is the prevailing bias among funders to support innovative, “breakthrough” ideas.2 Another is the fact that, for many people, the concept conjures up images of bureaucracy and centralized control. Such images are uninviting in any sphere, but they are especially problematic in the nonprofit sector, where local “ownership” by donors and volunteers plays such an important part in organizational success. Add in the fact that for many social entrepreneurs, autonomy is an important form of psychic income, and it becomes easy to understand why implementing someone else’s dream tends not to be nearly as satisfying as building one’s own. In practice, however, replication is anything but a cookie-cutter process. The objective is to reproduce a successful program’s results, not to slavishly recreate every one of its features. At the heart of replication is the movement of an organization’s theory of change to a new location. In some cases, this might entail transferring a handful of practices from one site to another; in others, the wholesale cloning of the organization’s culture. Whatever the specifics, the right choice – including whether to replicate at all – will be strongly influenced by the complexity of the organization’s theory of change and the degree to which it can be articulated and standardized.3 Before turning to replication in the social sector, however, it is worth spending a moment on its for-profit sector analogue, franchising. Born in the 1920s, the franchise has become one of the dominant organization forms of our time, accounting today for roughly 50 percent of all U.S. retail sales. Franchise organizations align the energy and investment of local entrepreneurs with the strength of a network that may encompass hundreds or even thousands of units operating under the same trademark in different locations. While there are sharp differences between the forprofit and nonprofit sectors, which limit the analogy, franchising offers some thought-provoking lessons for social enterprises seeking to grow.

1. Diving In: Nonprofits, NGOs, and Design: This discussion between Jocelyn Wyatt (@jocelynw) of IDEO.org and Jeff Wishnie (@jwishnie) of the UN Foundation’s Digital Impact Alliance highlights the opportunities and challenges of using human-centered design in the social sector. These tools—“designing with and for the human/user/beneficiary”—have huge promise for helping to create more effective and more desirable (and therefore scalable) interventions. This piece offers interesting thoughts on some different approaches for embedding them in a social sector organization. 2. How do you scale up an effective education intervention? Iteratively, that’s how: World Bank economist David Evans (@tukopamoja) writes about some important research on implementing and scaling interventions through government systems. The research paper he discusses, which is largely focused on the efforts of the fantastic education NGO Pratham (@prathamusa) and Indian government schools, shows the power of using impact assessments to iterate toward an improved “2.0” intervention. More of this type of implementation-focused research is needed! 3. From Gutenberg to Zuckerberg—The Transformation of Business: Mark Bonchek (@MarkBonchek) writes about how leaders reaching scale through a platform model must learn where and how to cede control of the platform to its users. He describes a “‘one-to-many” dynamic for distributing information that emerged with the printing press. In today’s platform models—which thrive by connecting “many-to-many”— hierarchy gives way to networks, and processes to principles. As the business world shifts to these more dynamic, relational models, I can’t help but wonder what the potential of these models might be for scaling in the social sector. (Yet it feels like we have just begun to scratch the surface.) 4. In the Fight Against Hunger, Technology Brings Power to the People: Beth Simone Noveck (@bethnoveck) writes about potent efforts to end hunger by using data to address food shortage and pricing problems. The systems changes necessary—from data transparency policies to mechanisms for crowdsourcing stakeholder data—to generate and exchange this kind of information on a large scale are significant, but there is also tremendous potential for using data to address system problems of this type at scale. 5. Can This Data-Driven Organization Help Those Most Desperate Escape Life on the Streets?: Finally, this profile of the work of Community Solutions (@cmtysolutions) offers insight into a compelling example of an ongoing transformative scale effort. Community Solutions has brought a data-driven approach to attempting to end homelessness, blending local action with a platform for comparing and sharing data, and embedding learning and improvement in their systems. Intriguingly, “because of this emphasis on data, Community Solutions increasingly thinks of itself as a tech company.” An exciting read with implications for many.

In this report, we present the AIDED model for guiding dissemination, diffusion, and scale up of family health innovations in low-income countries. The model was developed using in-depth interviews with experts and practitioners, a systematic review of peer-reviewed and gray literature, and pressure testing with multiple audiences. The AIDED model posits five interrelated components to the complex process of scale up: 1) assess, 2) innovate, 3) develop, 4) engage, and 5) devolve. We identify key activities in the five components that have been linked to successful scale-up efforts of selected family health innovations: Depo-Provera, exclusive breastfeeding, community health worker approaches, and social marketing. The model represents scale up as a complex adaptive system in which the several interlocking parts interact in diverse and sometimes unpredictable ways. Nonetheless, the indepth interviews and literature synthesis suggests important patterns that are prominent in successful scale-up efforts and less apparent in failed efforts. These include explicit, early investment in assessment of community receptivity to the innovation and of the key environmental forces that may promote or limit scale up; tailoring of the innovation to fit target user groups; development of political, regulatory, socio-cultural, and economic support for the use of the innovation in target user groups; deep engagement with target user groups to ensure that the innovation is translated, integrated, and replicated effectively; and devolving of efforts to spread the innovation from the index user groups to additional sets of user groups often through social and professional networks and relationships. We found only limited evidence for differences in effective scale-up approaches across the different innovation types.

Background:
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.

Over the last few years, the research and development communities have deemed “scaling” a priority in order to help contribute to and achieve the Sustainable Development Goals (SDGs). On smaller scales, there has been great success in reducing hunger and poverty, but it has rarely expanded to regional or national levels. The International Maize and Wheat Improvement Center (CIMMYT) scaling head Lennart Woltering, in collaboration with colleagues Kate Fehlenberg and Bruno Gerard, as well as with international development experts Jan Ubels of SNV and Larry Cooley of Management Systems International, have been studying the process of scaling to understand why successful pilot projects are no guarantee for success at scale. In a new paper published in Agricultural Systems, they argue that pilot projects are usually set up and managed in heavily controlled environments that do not reflect the reality at scale. Furthermore, confusion of what scaling is and how it can be executed often results in a narrow focus on solely reaching numbers. “Counting household adoption of a practice at the end of a project is a poor metric of whether these people can and will sustain adoption after the project ends, let alone if adoption will reach others and actually contributes to improved livelihoods,” Woltering states. According to Woltering, “This paper is a call for a new scaling narrative, from one that is short-term and piecemeal, to one that recognizes the systemic nature of problems and solutions to achieve sustainable change at scale.” This requires a change in mindset, skills and ways of collaborating than what we currently consider normal. “Meaningful impact at scale hardly occurs within a project context, but when new ways of working are becoming ‘the new normal’ by a critical mass of actors ‘in the real world’,” Woltering explained. The authors present a number of frameworks that help to assess the scalability of innovations and the design of scaling strategies from the onset of projects and how to systematically think through key elements needed for scaling success. This includes CIMMYT’s very own Scaling Scan. Reaching the SDGs requires scaling interventions to be seen as building blocks within a system of other initiatives with the same goals.

Background
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.

To achieve universal health coverage, the scale-up of high impact public health interventions is essential. However, scale-up is challenging and often not successful. Therefore, a systematic review was conducted to provide insights into the factors influencing the scale-up of public health interventions in low- and middle-income countries (LMICs). Two databases were searched for studies with a qualitative research component. The GRADE-CERQual approach was applied to assess the confidence in the evidence for each key review finding. A multi-level perspective on transition was applied to ensure a focus on vertical scale-up for sustainability. According to this theory, changes in the way of organizing (structure), doing (practice) and thinking (culture) need to take place to ensure the scale-up of an intervention. Among the most prominent factors influencing scale-up through changes in structure was the availability of financial, human and material resources. Inadequate supply chains were often barriers to scale-up. Advocacy activities positively influenced scale-up, and changes in the policy environment hindered or facilitated scale-up. The most outstanding factors influencing scale-up through changes in practice were the availability of a strategic plan for scale-up and the way in which training and supervision was conducted. Furthermore, collaborations such as community participation and partnerships facilitated scale-up, as well as the availability of research and monitoring and evaluation data. Factors influencing scale-up through a change in culture were less prominent in the literature. While some studies articulated the acceptability of the intervention in a given sociocultural environment, more emphasis was placed on the importance of stakeholders feeling a need for a specific intervention to facilitate its scale-up. All identified factors should be taken into account when scaling up public health interventions in LMICs. The different factors are strongly interlinked, and most of them are related to one crucial first step: the development of a scale-up strategy before scaling up.

To achieve universal health coverage, the scale-up of high impact public health interventions is essential. However, scale-up is challenging and often not successful. Therefore, a systematic review was conducted to provide insights into the factors influencing the scale-up of public health interventions in low- and middle-income countries (LMICs). Two databases were searched for studies with a qualitative research component. The GRADE-CERQual approach was applied to assess the confidence in the evidence for each key review finding. A multi-level perspective on transition was applied to ensure a focus on vertical scale-up for sustainability. According to this theory, changes in the way of organizing (structure), doing (practice) and thinking (culture) need to take place to ensure the scale-up of an intervention. Among the most prominent factors influencing scale-up through changes in structure was the availability of financial, human and material resources. Inadequate supply chains were often barriers to scale-up. Advocacy activities positively influenced scale-up, and changes in the policy environment hindered or facilitated scale-up. The most outstanding factors influencing scale-up through changes in practice were the availability of a strategic plan for scale-up and the way in which training and supervision was conducted. Furthermore, collaborations such as community participation and partnerships facilitated scale-up, as well as the availability of research and monitoring and evaluation data. Factors influencing scale-up through a change in culture were less prominent in the literature. While some studies articulated the acceptability of the intervention in a given sociocultural environment, more emphasis was placed on the importance of stakeholders feeling a need for a specific intervention to facilitate its scale-up. All identified factors should be taken into account when scaling up public health interventions in LMICs. The different factors are strongly interlinked, and most of them are related to one crucial first step: the development of a scale-up strategy before scaling up. Scale-up, public health interventions, barriers and facilitators, LMICs, systematic review

How does an INGO like CARE contribute to sustainable, systemic change at scale, far beyond the direct work we and our partners carry out with communities? That is the challenge we’ve put at the heart of our new 10-year strategy. Drawing on learning from within CARE’s programs and within the wider scaling up community, we have also developed a new guidance note, outlining six pathways to Impact at Scale. These pathways are framed around Riddell and Moore’s three approaches of scaling up, scaling out and scaling deep. The guidance note outlines a number of examples from CARE’s programs at global, regional or national levels, that apply different combinations of these pathways, as well as highlighting learning from other organizations working on scaling up.

The global humanitarian aid and development industry has a problem: innovation is everywhere, but examples of successfully scaled solutions are far less common. Even when we achieve impact at scale, the process can take decades. CARE’s Scale X Design Accelerator is bridging the gap between innovation and impact. We envision a future where we design for scale from the outset. Where pilot models are tested for scale and sustainability along with impact and proof of concept. Where development practitioners are armed with the science and skills needed for scaling. Where we distill our most promising solutions from the noise and give them the practical means to succeed.

This rapid review summarises the evidence on how to scale up inclusive approaches to complex social change. It looks at how to design scalable inclusive change interventions, as well as how to plan and manage the scale-up process. Focusing on interventions with the aim of reaching the most marginalised and transform social norms, it covers programmes aiming to deliver inclusive outcomes for women and girls (with a particular focus on preventing violence against women and girls) and persons with disabilities. To date, many interventions seeking to change harmful gender and disability norms have been implemented as small-scale projects. There are limited experiences of scale-up and fewer evaluations of these experiences. However, there are some documented case studies as well as emerging analysis that draw out lessons learned. From this evidence base, this rapid desk review identifies eight critical issues commonly highlighted as important considerations when scaling up inclusive change interventions: 1. Opportunities for systemic approach, including integrating political and community-level scale-up, and coordinating across multiple sectors and stakeholders 2. Political support for scale-up 3. Strategic choices: balancing reach, speed, cost, quality, equity, and sustainability 4. Catalysing change: tipping points, diffusion effects, and local champions 5. Locally grounded, participatory, and adaptive approaches 6. Long-term approaches with funding models to match 7. Cost-effective and financially feasible scale-up strategies 8. Measuring impact and sustainability.

What is it? At CASE at Duke, we’ve created a free tool to help you identify areas of weakness and clearly articulate areas of strength along seven key — but oft-neglected — foundations for impact at scale. What do you get? In minutes, you’ll answer questions and receive a custom report with areas for growth, what that growth should look like, and suggested resources to help get you there. How do I start? Assess your organization on all seven key elements together (38 questions), or explore them one-by-one.

In order to achieve population-wide health improvements, population health interventions found to be effective in a research setting need to be implemented as widely as possible. This involves a change of scale or a scaling up of the intervention. Scaling up such interventions is necessary to ensure the target population has access to the most effective services and programs available. However, not all interventions shown to be effective in a research setting are suitable for scaling up. The scalability of an intervention is not only determined by its effectiveness but other key issues such as the likely reach and adoption of the intervention, the costs of operating at scale, and the acceptability and fit of the intervention with the local context. It is important that attention is paid to the scalability of an intervention, so resources are allocated to interventions that are more likely to be successfully scaled up, and therefore more likely to have an impact on the health of the population as a whole. Scaling up is also more likely to be successful if a systematic approach to scaling up is adopted from the outset. Such an approach is required to help policy makers and practitioners address the substantial challenges faced when interventions are scaled up. For example, the same human, technical and financial resources available in the research setting in which the original intervention was tested may not be available when the intervention is scaled up. The intervention will need to be implemented in the ‘real world’ where few existing support systems may be in place and other pressing priorities and competing interests need to be considered. In addition, the context in which the intervention is scaled up is likely to be highly political, rapidly changing, and influenced by a variety of factors, inputs and relationships. Under such circumstances, successful scaling up calls for careful balancing between achieving desired outcomes and implementation constraints. It also requires an implementation process that uses and engages existing health system capacities, wherever possible, rather than imposing additional requirements and burdens on the system. Finally, the process of scaling up requires ongoing monitoring and the flexibility to adjust to changes in the political, social or organisational context. Introduction Scaling up refers to deliberate efforts to increase the impact of successfully tested health interventions to benefit more people and foster policy and program development on a lasting basis. However, at the current time, few policy makers and practitioners have skills in and knowledge of scaling up methods. Further, there are relatively few examples in the published literature where the steps and considerations involved in scaling up an intervention are described. As a consequence, population health interventions found to be effective in a research setting remain under-utilised by the field of population health

This course offers an accessible and robust introduction to the concepts of innovation and scaling.

As Western aid budgets are slashed and government involvement with aid programmes reduced, NGOs in the voluntary sector are finding themselves taking an ever-increasing share of development work overseas. As they do so, they are forced to grow and to assume new responsibilities, taking more important and wide-ranging decisions - in many cases, without having had the chance to step back and review the options before them and the best ways of maximizing the impact they make. This collection of essays explores the strategies available to NGOs to enhance their development work, reviewing the ways that options can be understood, appropriate programmes and likely problems.

In 2004 the World Bank and Chinese government co-hosted a major conference in Shanghai to identify lessons on delivering global development solutions at scale. In the ensuing decade, a small group of development thinkers and practitioners has sought to explore this topic further. Among them are Brookings Institution scholars who have built a dedicated work program on scaling up to support new research, advise implementing organizations, and bring interested parties together from across the global development community.

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

As social enterprises drive toward scaled impact, the journey can be accelerated—or significantly slowed—by the strategies and tactics used to manage resource needs. Accessing the right financing at the right points in the journey is critical to scaling success. As an analogy, consider the needs of a car with various options at the driver’s disposal to help navigate the road ahead. In this analogy, if you are a social entrepreneur, the car is your enterprise and you are the driver. With your car, you travel over a bumpy road, moving closer and closer to your end game or your target equilibrium change.4 Your car can travel on many pathways, and, as outlined in Pivoting to Impact, 5 you will face inevitable roadblocks and will need to make strategic pivots along the way. To be successful in financing this journey, you must set your course (understanding the rules of the road), determine which types of fuel you will use and when, and explore how you will use your car’s internal gears to help you navigate and accelerate.

As social enterprises drive toward scaled impact, the journey can be accelerated—or significantly slowed—by the strategies and tactics used to manage resource needs. Accessing the right financing at the right points in the journey is critical to scaling success. As an analogy, consider the needs of a car with various options at the driver’s disposal to help navigate the road ahead. In this analogy, if you are a social entrepreneur, the car is your enterprise and you are the driver. With your car, you travel over a bumpy road, moving closer and closer to your end game or your target equilibrium change.4 Your car can travel on many pathways, and, as outlined in Pivoting to Impact, 5 you will face inevitable roadblocks and will need to make strategic pivots along the way. To be successful in financing this journey, you must set your course (understanding the rules of the road), determine which types of fuel you will use and when, and explore how you will use your car’s internal gears to help you navigate and accelerate.

The international development community increasingly recognizes the need to go beyond fragmented, one-of projects. In response, there is now much talk and some action on scaling up successful innovations and pilot projects with an explicit goal of achieving sustainable impact at scale. However, many questions remain about the practical implications of pursuing a systematic scaling up approach and about how the approaches being pursued by diferent institutions and practitioners relate to each other. This paper considers two of the most widely used approaches to scaling up, developed in parallel during the mid-2000s. The first approach was devised by Management Systems International (MSI), a management consulting firm focused on designing and applying policy and management solutions to common development problems, mostly in developing countries. True to its mandate, MSI focused on designing a management framework for practitioners. MSI published the first version of a handbook in March 2006 under the title “Scaling Up – From Vision to Large-Scale Change: A Management Framework for Practitioners,” authored by Larry Cooley and Richard Kohl. Based on extensive experience applying this framework in diferent country and sectoral contexts, MSI issued a second, and substantially revised, edition of the handbook in 2012, under the same title and under the principal authorship of Larry Cooley and Rajani R. Ved. The second edition was accompanied by a scaling up toolkit publication, which provides details and examples of application for fifteen specific management tools referred to in the handbook.1 This approach is here referred to as the “MSI framework.” The second approach was initially developed in the Wolfensohn Center for Development at Brookings and published in 2008 in a Brookings working paper under the title “Scaling Up: A Framework and Lessons for Development Efectiveness from Literature and Practice,” by Arntraud Hartmann and Johannes Linn.2 This approach was then applied and further developed in the context of an institutional scaling up review of – and in collaboration with – the International Fund for Agricultural Development (IFAD), and in advisory and research undertakings with various aid agencies. In keeping with the objective of developing an institutional-level framework for IFAD, the approach aimed to provide high-level policy and operational guidance on the scaling up challenge. This approach is here referred to as the “IFAD framework.”3

Developing Economies Economic Development Global Development Global Poverty By 2030, an estimated 80 percent of the world’s extreme poor will live in “fragile states” where violent conflict is the most concentrated and vulnerability to natural disaster and climate change is on the rise. The current paradigm of promoting economic growth and poverty reduction will not work in the hardest places. Instead, responding to the challenges of fragility will require a new paradigm focused on sustainably meeting basic needs for hundreds of millions of the most vulnerable persons, managing shocks and stress that disrupt development, and addressing the root causes of fragility. None of these challenges can be properly addressed without working at scale. This is not simply a matter of expanding successful programs to reach more people. Instead, we argue that the most promising interventions for tackling fragility and building resilience only “kick-in” at scale because of the higher degree of functioning social capital they require. While not a panacea, scaling-up approaches provide a valuable organizing framework for strengthening and expanding social capital and overcoming the piecemeal, one-off, and non-strategic character of aid projects in fragile states. SCALING AS AN ORGANIZING FRAMEWORK Fragile states by definition face higher risks and insufficient capacities to deal with them at the community, state, or system level. Traditional pathways for service delivery—governments and markets—are often low capacity or otherwise compromised. In addition, international assistance is often piecemeal, short-term, and uncoordinated. Scaling frameworks offer a way to organize disparate capacities and resources among partners for the widespread and sustainable provision of basic services like health, water, and education. Scaling is arguably less risky than one-off projects. Several frameworks seek to unpack and improve the process of scaling valuable interventions. Among the most widely disseminated is Management Systems International’s framework, which (see the figure below) has three objectives—designing interventions with scale in mind, assessing scalability, and enhancing the scaling process—and is organized into three steps. Step 1 focuses on establishing and testing scalable interventions and viable pathways. Step 2, establishing the preconditions for scaling, focuses on the “political” tasks needed to support scaling. And, Step 3 includes the organizational, coordination, and accountability tasks essential for large-scale delivery and quality control.

This article proposes a new paradigm and management framework for programming in fragile states. Confronted by the root causes of fragility and the pressing needs of hundreds of millions of the world’s most vulnerable persons, it argues for focusing on both problems simultaneously. The article singles out four features that distinguish scaling strategies in fragile states and suggests that the most promising interventions for tackling fragility and building resilience only ‘kick-in’ at scale because of the higher degree of functioning social capital they require. The article cites a number of examples to support the view that scaling-up approaches provide a valuable organizing framework for integrating a focus on social capital into programming and overcoming the piecemeal, one-off and non-strategic character of aid programmes in fragile states.

It’s as if someone suddenly flipped a switch. Discussions about scale and scaling, previously considered esoteric topics, now appear in almost every conversation about ending poverty, saving lives, or protecting the planet. Whether focused on social enterprise or governmental action, social investment or fortunes at the base of the pyramid, these conversations acknowledge the need to confront explicitly the obstacles that stand between successful pilot projects and the solution to population-level problems. As two people who have worked on the issues of scale and scaling for more than a decade , we are pleased at the attention the issue of scale is receiving. But we believe that there is a central element missing from many of these discussions. That element relates to overcoming predictable obstacles that innovations face when moving from the margin to the mainstream. At one end of the “supply chain”, support for innovation enjoys robust funding, strong institutions, and widespread success witnessed in the proliferation of innovation hubs and grand challenges. At the other end of the chain, markets and governments have structures and funding models that allow them to deliver goods and services sustainably at scale. But these two parts of the chain are separated by a broken link. We refer to this broken link as “intermediation” and it is the subject of this paper.

The concept of “scaling up” has become increasingly popular as concerned donors note the relatively poor record of innovative pilot projects in extending their reach to large populations. The Scaling Up Management (SUM) FRAMEWORK and the guidelines presented in this document seek to improve this track record through practical advice on a three‐step, ten task process for effective scaling up. Scaling up is drawing the attention of a widening circle of donors, philanthropists, governments, NGOs, activists, and researchers as growing concerns emerge regarding the challenge of reaching large numbers of those in need. Despite this growing interest and an expanding array of documented cases, relatively little evidence‐based guidance exists about how to maximize prospects for new and innovative service delivery models to achieve scale. Written primarily for officials charged with making funding decisions and implementing programs, this paper seeks to provide concrete advice derived from theory and practice. It is intended to inform decisions regarding: Selecting projects with the potential to go to scale Designing projects to maximize their scalability Managing the scaling up process The SUM FRAMEWORK presented in this publication is organized as a series of steps and tasks based on the conviction that scaling up can be successfully managed. It is our hope that the development and humanitarian communities will in future years be filled with a growing number of entrepreneurial idealists who are able to bring ever‐increasing professionalism to the scaling up process.

The concept of “scaling up” has become increasingly popular as concerned donors and service providers find themselves under pressure to reduce costs, improve social outcomes, and explain why it has proven so difficult to accelerate the spread of best practices. To support this effort, the SUM Framework was developed to serve three related objectives, namely: To provide an easily understood and straightforward way for donors and investors to assess the scalability of proposed interventions; To provide guidelines for designing pilot projects and other innovations “with scale in mind”; and To provide tools and approaches to help practitioners manage the scaling up process. Scaling up has drawn the attention of a widening circle of donors, philanthropists, governments, NGOs, activists, social investors and researchers galvanized by the challenge of solving big problems and reaching large numbers of those in need. Despite this growing interest and an expanding array of documented cases, relatively little evidence-based guidance exists about how to maximize prospects for new and innovative products and service delivery models achieving and sustaining outcomes at scale. Written primarily for officials charged with making funding decisions and implementing programs, this paper seeks to provide concrete advice derived from theory and practice. It is intended to inform decisions regarding: Selecting projects with the potential to go to scale, Designing projects to maximize their scalability; and Managing the scaling up process The SUM Framework is organized as a series of steps and tasks based on the conviction that scaling up can be successfully planned and managed. It is our hope that future years will witness a growing number of entrepreneurial idealists able to bring ever-increasing professionalism to the scaling up process.

The concept of “scaling up” has become increasingly popular as donors have acknowledged with concern the relatively poor record of innovative pilot projects in extending their reach to large populations. Recognizing this, in October 2003, the John D. and Catherine T. MacArthur Foundation awarded a grant to Management Systems International (MSI) to develop a field-tested framework and set of guidelines for improved management of the scaling-up process. This framework was intended to be of direct and immediate use to those planning, implementing, and funding pilot projects and to those hoping to take the results of such projects to scale. An earlier draft of the Scaling Up Management (SUM) Framework was used in field tests with reproductive health non-governmental organizations (NGOs) in Nigeria and Mexico and as a basis for initial dissemination efforts. This revised version of the framework reflects that experience and incorporates the feedback from initial dissemination. One significant finding emerged from this research: Few so-called “pilot projects” take the steps needed to maximize their prospects for scaling up. The framework and guidelines presented in this document seek to improve this track record by offering practical advice on a three-step process to carry out each of ten key tasks needed for effective scaling up. Scaling up is drawing the attention of an ever-increasing circle of donors, philanthropists, governments, NGOs, activists, and researchers. As interest grows, so do their concerns regarding the replicability of successful innovations and the challenges of reaching large numbers of those in need. Despite this growing interest and an expanding array of documented cases, relatively little evidence-based advice exists about maximizing the prospects for new and innovative service-delivery models to achieve scale. Written primarily for officials charged with making funding decisions and implementing programs, this paper seeks to provide concrete advice derived from theory and practice. It is intended to inform decisions about: Y Selecting projects with the potential to go to scale; Y Designing projects to maximize their scalability; and Y Managing the scaling-up process. The SUM Framework presented in this publication is organized as a series of Steps and Tasks. This approach is based on the conviction that scaling up can be successfully managed and that this process can be carried out most effectively by breaking it down into concrete strategies and actions. It is our hope that the development and humanitarian communities will be filled in future years with a growing number of entrepreneurial idealists bringing everincreasing professionalism to the scalingup process.

‘Localisation’ and ‘scale’ – two of the most dominant themes in recent development debates – are born of separate but related frustrations with the legacy and architecture of international development. In localisation’s case, this frustration begins with a rejection of the proposition that the wisdom and legitimacy to shape the destiny of a country, organisation, community or individual can come from the outside. In the case of scaling, the frustration reflects a recognition that donor-funded projects and philanthropy are rarely, if ever, sufficient to produce sustainable development outcomes at scale. Although the constituencies and arguments in support of the movement supporting localisation and the movement supporting scaling continue to be quite separate, we argue that the two frustrations – and therefore the two movements – should be seen as flip sides of the same coin.

Development effectiveness by governments and development funders requires that their actions result in sustainable impact at scale, i.e., that they address identified development problems to a significant and measurable extent and on a sustained basis. In most cases, sustainable impact at scale cannot be achieved over short time horizons or spontaneously. It requires deliberate, systematic and sustained action by public and private agencies, supported by third-party funders, in pursuit of a trajectory of action (“scaling pathway”) that takes a specific intervention or a set of policy or institutional reforms as the starting point and eventually leads to sustainable impact at scale. 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.

The concept of “scaling up” has become increasingly popular as concerned donors note the relatively poor record of innovative pilot projects in extending their reach to large populations. The Scaling Up Management (SUM) FRAMEWORK and the guidelines presented in this document seek to improve this track record through practical advice on a three‐step, ten task process for effective scaling up. These steps and tasks include: Step 1: Develop a Scaling Up Plan Task 1: Create a Vision 1A. The Model: What Is Being Scaled Up? 1B. The Methods: How Will Scaling Up Be Accomplished? 1C. Organizational Roles: Who Performs the Key Functions? 1D. Dimensions of Scaling Up: Where and For Whom Does Scaling Up Occur? Task 2: Assess Scalability 2A. Determining the Viability of the Model for Scaling Up 2B. Analyzing the Organizational and Social Context Task 3: Fill Information Gaps Task 4: Prepare a Scaling Up Plan Step 2: Establish the Pre‐Conditions for Scaling Up Task 5: Legitimize Change Task 6: Build a Constituency Task 7: Realign and Mobilize Resources Step 3: Implement the Scaling Up Process Task 8: Modify Organizational Structures Task 9: Coordinate Action Task 10: Track Performance and Maintain Momentum The theory and practice underlying the FRAMEWORK come from the discipline of “strategic management.” More specifically, Step 1 brings to bear best practices related to strategic planning in complex settings; Step 2 focuses on change management functions associated with consensus building, policy change, and resource allocation; and Step 3 emphasizes the operational aspects of multi‐actor program implementation. Scaling up is drawing the attention of a widening circle of donors, philanthropists, governments, NGOs, activists, and researchers as growing concerns emerge regarding the challenge of reaching large numbers of those in need. Despite this growing interest and an expanding array of documented cases, relatively little evidence‐based guidance exists about how to maximize prospects for new and innovative service delivery models to achieve scale. Written primarily for officials charged with making funding decisions and implementing programs, this paper seeks to provide concrete advice derived from theory and practice. It is intended to inform decisions regarding: Selecting projects with the potential to go to scale Designing projects to maximize their scalability Managing the scaling up process The SUM FRAMEWORK presented in this publication is organized as a series of steps and tasks based on the conviction that scaling up can be successfully managed. It is our hope that the development and humanitarian communities will in future years be filled with a growing number of entrepreneurial idealists who are able to bring ever‐increasing professionalism to the scaling up process.

This paper briefly summarizes definitions, approaches, and challenges to achieving “scale” in community-focused health programs as discussed at the 2005 CORE spring meeting and the USAID child survival and health grants program mini-university. This paper is meant to harmonize a vocabulary for use by NGOs and their partners as they further discuss, debate, and analyze how NGOs and their partners can reach more people with high quality maternal, child and neonatal health interventions. Case studies and further documentation of discussions on scale can be found in the proceedings from the CORE Spring 2005 Meeting available on the CORE website

Extreme poverty, climate change, racial injustice. As the world’s problems accelerate, so should our solutions. Mission to Scale reveals the tools, mindsets and strategies that organizations and funders need — to make the most impact. On the podcast, Spring Impact Founder Dan Berelowitz talks to brilliant leaders from today’s most dynamic nonprofits, social enterprises, and purpose-driven brands about pursuing change, at scale. From creating lean strategy to team building, each episode helps you take the guesswork out of changing more lives. This podcast is a production of Spring Impact and Hueman Group Media.

Background:
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.

Prolonged sitting has been linked to adverse health outcomes; therefore, we developed and examined a web-based, computer-tailored workplace sitting intervention. As we had previously shown good effectiveness, the next stage was to conduct a dissemination study. This study reports on the dissemination efforts of a health promotion organisation, associated costs, reach achieved, and attributes of the website users. The organisation systematically registered all the time and resources invested to promote the intervention. Website usage statistics (reach) and descriptive statistics (website users’ attributes) were also assessed. Online strategies (promotion on their homepage; sending e-mails, newsletters, Twitter, Facebook and LinkedIn posts to professional partners) were the main dissemination methods. The total time investment was 25.6 h, which cost approximately 845 EUR in salaries. After sixteen months, 1599 adults had visited the website and 1500 (93.8%) completed the survey to receive personalized sitting advice. This sample was 38.3 ± 11.0 years, mainly female (76.9%), college/university educated (89.0%), highly sedentary (88.5% sat >8 h/day) and intending to change (93.0%) their sitting. Given the small time and money investment, these outcomes are positive and indicate the potential for wide-scale dissemination. However, more efforts are needed to reach men, non-college/university educated employees, and those not intending behavioural change.

In this article we explore whether and how the dynamics of access shape the scaling of modern agricultural technologies. It is based on the experience of an agricultural research for development (AR4D) project called CASCAPE, which aims to validate and scale agricultural best practices for smallholder farmers in Ethiopia. The socio-political dynamics of external interventions are often taken for granted contextual factors in AR4D projects. By contrast, this article takes this context as the point of departure for its analysis. The aim of this in-depth case study is to unpack the concept of access as condition for scaling of agricultural technologies. We identify and analyse the mechanisms that determine access to the various components of a malt barley technology package which was introduced in two highland communities in southern Ethiopia (and later ‘scaled’ to a range of other communities). Our research approach is technographic, implying that we consider the technology to contain both material and social components. The findings suggest that social and clan-based exchange mechanisms (such as clan-based loyalty, reciprocity and vertical accountability) are often rendered invisible even though they are of critical importance in governing access to the material and social components of modern agricultural technologies. Ignoring this socio-political context in the malt barley interventions resulted in an unintended scaling effect in terms of widening the social and economic gap between a few better off farmers and a larger group of poor farmers. The paper thus provides evidence that the socio-political dynamics of access to technology can have an important influence on its wide spread application and may complicate efforts to scale the uptake of technology. Paying more attention to such processes would help to improve the effectiveness of AR4D efforts.

Aspects of the research and practice paradigm known as the diffusion of innovations are applicable to the complex context of health care, for both explanatory and interventionist purposes. This article answers the question, “What is diffusion?” by identifying the parameters of diffusion processes: what they are, how they operate, and why worthy innovations in health care do not spread more rapidly. We clarify how the diffusion of innovations is related to processes of dissemination and implementation, sustainability, improvement activity, and scale-up, and we suggest the diffusion principles that can be readily used in the design of interventions. TOPICS IMPROVING CARE PERFORMANCE MEASURES QUALITY IMPROVEMENT INITIATIVES SYSTEMS OF CARE PUBLIC HEALTH

The principles of strategic management suggest that a major step in ensuring effective scaling up is to understand the diverse environments in which health service innovations are expanded. When service innovations are expanded in the public sector, the political and administrative institutions, as well as the health sector setting constitute major environmental influences. This chapter analyses these factors in Brazil, using the experience of a project which sought to enhance equitable access and improve the quality of care in public sector family planning services. Nongovernmental organizations acted as the resource team that facilitated the testing of the original service innovations in one municipality and then assisted with their expansion to others. The chapter shows that scaling up is influenced by an ongoing process of decentralization and by the politics of family planning. Scaling up family planning innovations faces special challenges, which would not be encountered in other areas of reproductive health in Brazil.

As governments seek to meet the global health agendas of the past decade, new approaches to the training of health professionals are needed. Training must move away from an exclusive focus on technical skills and begin to incorporate educational strategies that empower providers, programme managers and community leaders to become agents of change. This chapter describes a methodology for in-service training that builds on Paulo Freire’s educational philosophy and explains how the capacity to provide innovative training was scaled up in public sector reproductive health services in Brazil, Bolivia and Chile. Statistics on the training sessions demonstrate the reach of this training initiative, and testimonials show its profound impact on newly trained trainers.

Before 2013, Senegal public health supply system was pull-based and fully public-run. Lengthy and recurrent stockouts of essential health products (incl. contraceptives) were the rule, not the exception as they used to strike more than 80% of public service delivery points (SDPs). Following a successful pilot in two districts in 2012, the Senegalese Ministry of Health and Social Action (MSAS) implemented the Informed Push Model (IPM) Project (2013–2016). In its first two years, IPM bridged key gaps and expanded the distribution of contraceptives by private third party logistics operators to all public SDPs in Senegal and nearly eliminated stockouts. However, the MSAS was slow to take ownership of the project. Understanding the roots of this reluctance, executing a range of targeted communication and advocacy efforts and preparing a strong transition plan are succeeding to push Government toward full ownership to enable the National Supply Pharmacy to distribute all health products going to SDPs, including vaccines, consistently with their Strategic Plan 2014–2018.

Universal coverage of essential interventions would reduce neonatal deaths by an estimated 71%, benefi t women and children after the fi rst month, and reduce stillbirths. However, the packages with the greatest eff ect (care around birth, care of small and ill newborn babies), have low and inequitable coverage and are the most sensitive markers of health system function. In eight of the 13 countries with the most neonatal deaths (55% worldwide), we undertook a systematic assessment of bottlenecks to essential maternal and newborn health care, involving more than 600 experts. Of 2465 bottlenecks identifi ed, common constraints were found in all high-burden countries, notably regarding the health workforce, fi nancing, and service delivery. However, bottlenecks for specifi c interventions might diff er across similar health systems. For example, the implementation of kangaroo mother care was noted as challenging in the four Asian country workshops, but was regarded as a feasible aspect of preterm care by respondents in the four African countries. If all high-burden countries achieved the neonatal mortality rates of their region’s fastest progressing countries, then the mortality goal of ten per 1000 livebirths by 2035 recommended in this Series and the Every Newborn Action Plan would be exceeded. We therefore examined fast progressing countries to identify strategies to reduce neonatal mortality. We identifi ed several key factors: (1) workforce planning to increase numbers and upgrade specifi c skills for care at birth and of small and ill newborn babies, task sharing, incentives for rural health workers; (2) fi nancial protection measures, such as expansion of health insurance, conditional cash transfers, and performance-based fi nancing; and (3) dynamic leadership including innovation and community empowerment. Adapting from the 2005 Lancet Series on neonatal survival and drawing on this Every Newborn Series, we propose a country-led, data-driven process to sharpen national health plans, seize opportunities to address the quality gap for care at birth and care of small and ill newborn babies, and systematically scale up care to reach every mother and newborn baby, particularly the poorest.

The International Livestock Research Institute (ILRI) works to improve food and nutritional security and reduce poverty in developing countries through research for efficient, safe and sustainable use of livestock. ILRI’s core business is to undertake livestock research for development. However, translating research outputs into outcomes, and ultimately to impact at scale, has been an enduring challenge for ILRI, other CGIAR centres and research institutions. To address this challenge, ILRI needs to adopt evidence-based development approaches and methods of achieving impact at scale, and maximize the probability of success by working in partnership with development partners such as the private sector, governments, NGOs, development banks, etc. In 2017, ILRI created the Impact at Scale Program (I@S) to ensure the organization has the requisite expertise to manage projects that are rooted in development, effectively partner with other organizations to deliver at scale and ensure it can demonstrate the impact of its livestock research for development. One of the key product lines of I@S is designed to provide the institute and its key partners with a framework for scaling proven technologies and solutions. This includes coming up with a systematic and pragmatic approach to scaling by scanning ILRI’s research portfolio to identify readiness for scaling different solutions. This is meant to provide a clear and objective picture of current and long-term trends with regards to the scaling potential of different priority commodities, geographies, themes in ILRI programs, the institute overall and the wider livestock sector. Lack of appropriate systems to apply existing scaling tools can be a challenge for ILRI and CGIAR when trying to design and execute research projects with the end in mind. To make scaling concepts and tools more accessible to ILRI and CGIAR researchers and their partners, I@S has reviewed the landscape of scaling in the context of agricultural research for development with the aim of summarizing relevant approaches and tools that livestock projects can embed along with a detailed process on how they can be supported and implemented systematically. This document provides an overview of the steps in a scaling process as envisaged for ILRI and provides short summaries of nine tools related to scalability assessment developed by research institutes, development agencies, nonprofit organizations and private companies. The document also provides a summary of our assessment of these tools. By applying these tools and principles, we hope research projects will achieve a better “scaling mindset” from the early stages of project design. The outlined process hinges on the close involvement and expertise of project teams across ILRI and CGIAR to ensure ownership and a shared understanding of scaling objectives. It also depends on the commitment of scaling coordinators who help facilitate smooth implementation of scaling assessments and subsequent tracking and implementation of scaling plans. By design, the approach is iterative and agile and focuses on practical steps and facilitating skills and approaches that allow projects to identify and adapt to changes quickly. When reviewing the tools, our aim was to curate a process that would be “fit for purpose” for the ILRI/ CGIAR operational environment. Therefore, we focused on a set of evaluation criteria that we felt were most relevant to this goal. A summary table is provided below, and a more detailed description of the methodology used and the rationale for our selection can be found in Table 2, Part II: Synthesis on scaling tools and guides.

This paper discusses the role that impact evaluations should play in scaling up. Credible impact evaluations are needed to ensure that the most effective programs are scaled up at the national or international levels. Scaling up is possible only if a case can be made that programs that have been successful on a small scale would work in other contexts. Therefore the very objective of scaling up implies that learning from experience is possible. Because programs that have been shown to be successful can be replicated in other countries while unsuccessful programs can be abandoned, impact evaluations are international public goods, thus the international agencies should have a key role in promoting and financing them. In doing this, they would achieve three important objectives: improve the rates of return on the programs they support, improve the rates of return on the programs other policymakers support by providing evidence on the basis of which programs can be selected, and build long-term support for international aid and development by making it possible to credibly signal what programs work and what programs do not work. The paper argues that considerable scope exists for expanding the use of randomized evaluations. For a broad class of development programs, randomized evaluation can be used to overcome the problems often encountered when using current evaluation practices.

As Western aid budgets are slashed and government involvement with aid programmes reduced, NGOs in the voluntary sector are finding themselves taking an ever-increasing share of development work overseas. As they do so, they are forced to grow and to assume new responsibilities, taking more important and wide-ranging decisions - in many cases, without having had the chance to step back and review the options before them and the best ways of maximizing the impact they make. This collection of essays explores the strategies available to NGOs to enhance their development work, reviewing the ways that options can be understood, appropriate programmes and likely problems.

Over the past decade, the humanitarian sector has started to invest more heavily in innovation, seeking new and more efficient solutions to humanitarian crises. Elrha established its pioneering Humanitarian Innovation Fund in 2011, responding to the sector’s need for more innovative approaches to aid delivery, and advocated strongly for an increased focus on humanitarian innovation, including at the World Humanitarian Summit in 2016. More recently, innovation units have become commonplace in the large agencies that dominate the sector, while innovationfocused incubators and funding initiatives continue to emerge. While this is an overwhelmingly positive trend, investment in research and development in the humanitarian sector remains low compared to other sectors;5 5 By ‘research and development’, we specifically mean activities oriented towards the development and testing of solutions and approaches to humanitarian problems, including innovation activities and empirical research. For a discussion on levels of R&D investment in the humanitarian sector as compared with other sectors see footnote 6 the best effort to quantify spending to date on research and development identifies it at less than 0.2%.

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.

The Sustainable Development Goals (SDGs) were agreed upon unanimously in 2015 by the United Nations General Assembly and are due to be achieved by 2030. However, progress has been too slow and incomplete, with recent events such as the COVID-19 pandemic and the global economic crisis caused by the Ukraine war further setting back progress, especially in regard to poverty and food security targets. Although the common response to this shortfall has been to argue for more international development and climate finance, for policy and institutional reform aimed at monitoring progress towards the SDGs and climate goals, and for innovative solutions, this article argues that such efforts are not enough. This article therefore proposes a ‘scaling approach’ to investment programme/project design and implementation, whereby the programme/project supports a scaling pathway towards a long-term vision of development impact explicitly linked to the appropriate SDG and climate targets. This approach addresses the failings of the current one-off programme/project approach, which promotes the piloting of innovative features without a clear vision of whether and how successful interventions can be sustainably replicated and scaled (‘pilots to nowhere’).

You’ve designed a program to help more children learn to read, or to reduce the number of women who die in childbirth, or to increase how much wheat farmers grow. You pilot the program. You even invest in a careful evaluation. It works. Fantastic news! You realize that this could benefit so many more people than just the participants in your little pilot, so you convince a government agency to scale it up, or maybe you get funding to scale it up yourself. But at scale, the promised results fail to materialize. So what happened? Interventions that are effective at scale are the golden nuggets of public policy: valuable, rare, and even apparent winners are often revealed to be fool’s gold. They can be so challenging to find that you could be tempted to throw up your hands and say that “Nothing scales!” While that’s an overstatement (many interventions have had positive impacts at scale), there are also many, many failures. What factors drive the drop (or, in some cases, disappearance) of impacts as programs go from pilot to scale, and how can we avoid them?

The social sector invests a great deal of time and money trying to create social innovations, but pays scant attention to the challenges of spreading successful ones to other locations. Disseminating innovations takes a distinct, sophisticated skill set, one that often requires customizing the program to new circumstances, not replicating. The uneven distribution of social benefits may be partly due to inevitable lag times in spreading good ideas. We believe, however, that clumsy or weakhearted attempts at dissemination also have kept best practices from spreading. The principal at Chicago’s Providence-St. Mel said that the school’s accomplishments “are not rocket science,” but there is indeed a science behind transplanting innovations, one that can be learned partly from successful examples. Such learning will grow more likely where enthusiasts for social benefits recognize that creating social innovations and disseminating them call upon vastly different talents, and where the people who want to launch an innovation in a new location are fully prepared to customize it for the new locale—even, perhaps especially, when that means giving up the glory and the credit to achieve the greater goal. Customization requires slogging labor and is more nuanced than replication, but it is often the only way that a successful but orphaned innovation can take root elsewhere. For us, putting in that extra effort has made all the difference.

Evidence to Action CoP curated this selection of peer-reviewed articles, reports, briefs, and other grey literature that address systematic approaches to scaling up. It constitutes literature of relevance to the discussions of the Community of Practice on Systematic Approaches to Scaling Up. Topics include: Definitions of scaling up, Special issues or components of scaling up, Low- and middle-income countries, Family planning/reproductive health

As governments seek to meet the global health agendas of the past decade, new approaches to the training of health professionals are needed. Training must move away from an exclusive focus on technical skills and begin to incorporate educational strategies that empower providers, programme managers and community leaders to become agents of change. This chapter describes a methodology for in-service training that builds on Paulo Freire’s educational philosophy and explains how the capacity to provide innovative training was scaled up in public sector reproductive health services in Brazil, Bolivia and Chile. Statistics on the training sessions demonstrate the reach of this training initiative, and testimonials show its profound impact on newly trained trainers."

The SDGs are an urgent call for action by all countries to tackle global inequities in the spirit of partnership. They recognise that ending poverty and other deprivations must go together with improving health and education, reducing inequality, and spurring economic growth while tackling climate change. Promoting sustainable industries, creating localised solutions, and investing in innovation, are important ways to facilitate sustainable development – which has been adversely impacted in recent years. Creating a platform for innovators, entrepreneurs, communities and individuals to meet, share and build networks to scale locations solutions is essential towards achieving the SDGs.

Abstract Public sector health systems that provide services to poor and marginalized populations in developing countries face great challenges. Change associated with health sector reform and structural adjustment often leaves these already-strained institutions with fewer resources and insufficient capacity to relieve health burdens. The Strategic Approach to Strengthening Reproductive Health Policies and Programs is a methodological innovation developed by the World Health Organization and its partners to help countries identify and prioritize their reproductive health service needs, test appropriate interventions, and scale up successful innovations to a subnational or national level. The participatory, interdisciplinary, and country-owned process can set in motion much-needed change. We describe key features of this approach, provide illustrations from country experiences, and use insights from the diffusion of innovation literature to explain the approach\'s dissemination and sustainability.

This chapter analyses the process of scaling up introduction of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA) as part of a package of interventions to improve quality of care in the provision of all contraceptives in the Vietnamese family planning programme. After a strategic assessment of the need for contraceptive introduction and pilot testing of the interventions in three provinces, these interventions were scaled up to 21 of Viet Nam’s 64 provinces. Although DMPA was widely introduced, going to scale did not fully achieve the gains in quality of care for all methods found in the pilot phase. Three interrelated variables affected this outcome: the degree of change required in the service delivery system, the pace of expansion, and available resources to support expansion. In this case, scaling up proceeded faster than was desirable, given the extensive changes entailed by the interventions and the limitations in resources. Before embarking on rapid expansion involving complex programmatic changes, planners of scaling-up strategies should carefully assess the balance between these three variables.

Introduction:
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.

Hundreds of pilot studies of health innovations have been conducted around the world. Evaluations of many of them have revealed positive results on intended health outcomes. Yet few of these successfully-piloted innovations have been taken to scale, with fewer still scaled up sustainably. This is at least partially due to our lack of understanding of the scale-up process and to gaps in our knowledge of how to monitor and evaluate this process. Whether the innovation involves introducing new methods of contraception, decreasing HIV transmission from mother to child, or improving post-abortion care, taking ‘what works’ to scale is neither linear nor quick (Patton, 2011). The experience of the Institute for Reproductive Health, Georgetown University (IRH) scaling up Standard Days Method® (SDM) in five countries suggests that monitoring and evaluation (M&E) practices geared specifically toward the scale-up phase can increase the probability of achieving sustainable, large-scale implementation by providing real-time feedback designed to meet stakeholder needs. The research-to-practice continuum can be conceptualized in three phases: pilot, scaling up, and large scale implementation. The particular M&E approaches and tools most appropriate and effective for each stage vary considerably. During the pilot phase, the M&E priority is to accurately measure the effect of an innovation, the complete package of interventions to be scaled up. During the scale-up period, the emphasis shifts to measuring processes to ensure the innovation is implemented with fidelity, at an acceptable pace, and achieves desired coverage, while maintaining the fidelity of the innovation. Once an innovation is operating at scale, that is, has become a routine part of services, efforts continue to measure fidelity, but may also include determination of population-level impact. M&E processes, indicators, benchmarks, and data collection methods need to reflect these evolving priorities. The M&E process, as well as the information it generates, can support the scale-up process by helping stakeholders clearly define the innovation, maintain fidelity as the reach of the program expands, identify the need for adaptations, and ensure that the adapted innovation continues to produce the desired effect. A collaborative process of benchmarking, process documentation, and continuous feedback will engage stakeholders and involve new partners as services expand. This process can also help these stakeholders remain attentive and make midcourse adjustments as needed, to ensure that scale-up remains on track in a changing environment. M&E data can also verify that the evolving innovation maintains its effectiveness, and it can provide opportunities to advocate for investment and partnerships, while fostering discussions which reinforce the core values of the innovation.

Introduction:
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.

The premise of this book is that the concept of "spread" and the business of "spreading good practice" as we continue to apply it in healthcare, may be a large part of why "spread" doesn't happen. If you're looking for an alternative and occasionally irreverent view, then read on. This is a personal account reflecting on many years worth of consulting practice, mistakes included. aims behaviour better ideas blood letting change management change process chapter communication context Crossing the Canyon customisation developed diabetes difficult Diffusion of Innovations DoI engagement ensure example expect facilitation feedback focus FURTHER READING goal happens idea bias identified important improvement projects influence initiatives instant messaging IPOD issues learning look management rollout mean measurement plan medical errors models niche nini’s norm opinion leaders opinion leadership organisation Pareto Pareto analysis Pareto chart patients PDSA cycles pilot sites population of impact potential adopters pragmatists PRESENTING SYMPTOMS PREVENTING OCCURRENCES primary care practices problem process measures PROGNOSIS project management project team quality improvement reinvention Seth Godin social networking solution specific spread and adoption spread phase spread plan spread programs spreading good practice strategy successful change SUGGESTED TREATMENT target population techniques theory topic virtual virtual teams

Many people in developing countries lack access to health technologies even basic ones. Why do these problems in access persist? What can be done to improve access to good health technologies especially for poor people in poor countries? This book answers those questions by developing a comprehensive analytical framework for access and examining six case studies to explain why some health technologies achieved more access than others. The technologies include praziquantel (for the treatment of schistosomiasis) hepatitis B vaccine malaria rapid diagnostic tests vaccine vial monitors for temperature exposure the Norplant implant contraceptive and female condoms. Based on research studies commissioned by the Bill & Melinda Gates Foundation to better understand the development adoption and uptake of health technologies in poor countries the book concludes with specific lessons on strategies to improve access. These lessons will be of keen interest to students of health and development public health professionals and health technology developers -- all who seek to improve access to health technologies in poor countries.

Grow your start-up into a global influence with real-world impact Scaling Global Change provides social entrepreneurs with the strong organizational foundation they need to change the world. Through the story of Room to Read, one of the fastest-growing nonprofits in the last 18 years, this book features clear, real-world lessons for growing a non-profit or social enterprise, with special insight into girls’ education and literacy programming in lower-income countries. By outlining theories of program, operational, and system-level change, the discussion delves into the meat of the entrepreneurial spirit and applies it directly to everyday strategic decisions. The book begins with an overview of essential communication, vision, and execution fundamentals, and then dives into a discussion of metrics, monitoring, planning, leadership, and more. Clear guidance on internal operations, fundraising, team building, management, and other central topics provides a roadmap for new and experienced leaders, while further exploration of influence, strategy, and government funding relates the wisdom of experience from the perspective of a successful organization. Cross the chasm from start-up to mature organization with worldwide impact Gain insight into the theoretical and practical underpinnings of nonprofit success Adopt new perspectives on effectiveness, excellence, and influence Translate ideas into action in a way that will change the world Social entrepreneurship has taken off more than ever, and the market is crowded with optimistic leaders wanting to change the world. How do you differentiate your organization from the pack? How can you stand out, stand up, and make a real impact? These lessons are gained through experience and building a strong organizational culture; Room to Read has treaded this path and found itself at the heights of success. With Scaling Global Change, you reap the benefit of experiential lessons while applying them to the success of your own organization.

As program designers and implementers, how do we make sure our intervention will scale up? As program evaluators, how do we know if something is going to scale up? In 2018, we at the GEF IEO decided to find out by looking at completed projects that reported both successful and less successful scaling outcomes.

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.

Key findings of evaluation

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.

Change is the only constant, we all learn sooner or later. But what to do when political and economic changes threaten the success of your carefully-implemented program?

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.

When we at the GEF IEO looked at how impact was scaled up in GEF-supported interventions, many of the interviewees used terms such as “magic moment”, “luck” or “perfect storm” when referring to how scaling-up happened “spontaneously” through serendipitous circumstances, even when the project itself had no concrete plans for scaling-up. On the other hand, we also know how seemingly successful programs can quickly fall apart under political and economic changes.

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.

In early 2014, the Ebola virus began its devastation of West Africa, moving through countries, communities, and families with grim efficiency. Over the next two years, 60 percent of those infected with the virus died—more than 11,000 people. A brutal killer, Ebola renders its victims delirious and unable to cope on their own. One of the hardest-hit countries was Sierra Leone, which had just 136 doctors for more than 6 million inhabitants. Almost immediately, it fell to family and friends to act as caregivers. Ebola killed them, too. In the worst-hit areas, the virus eliminated entire families. Those who fell ill started running off to die alone rather than risk infecting loved ones. Eventually, social gatherings were banned, schools were closed, and households were separated. Society and the economy ground to a halt. The crisis was unprecedented. Since Ebola was first detected in 1976, each of the subsequent 27 outbreaks was stopped in less than three months—until 2014. Why did this outbreak last for two years and kill more than all previous outbreaks combined? A complete answer has yet to emerge, but two factors were critical. First, we lacked know-how. There were no preexisting, evidence-based solutions to combat an outbreak of this magnitude. Second, the context was pernicious. A variety of circumstances, including unprepared health systems at the national level and social disintegration, compounded the problem and destabilized even the most holistic solutions. In these types of circumstances, the way we usually scale solutions is ineffective. The traditional approach to delivering interventions at scale starts with the assumption that we have reliable solutions and favorable contexts. When this is the case, as it sometimes is, we are urged to scale what works by efficiently allocating resources to organizations with evidence-based solutions. But as the Ebola crisis shows, this is not always the case. Many of our most pressing problems are the ones we have been unable to solve, perhaps for years, for decades, or longer. Most are not crises on par with an Ebola outbreak, but fixtures of the status quo. Issues that in the development sphere are often called “wicked problems.” So, how do we scale when we don’t know what works?

Despite progress in developing more effective training methodologies, training initiatives for health workers continue to experience common pitfalls that have beset the overall success and cost-effectiveness of these programs for decades. These include lack of country-level coordination of health training, inequitable access to training, interrupted services, and failure to reinforce skills and knowledge training by addressing other performance factors. These pitfalls are now seen as aggravating the current crisis in human resources for health and impeding the effective scale-up of training and the potential impact of promising strategies such as task shifting to address health worker shortages. Drawing on IntraHealth International's lessons learned in designing reproductive health and HIV/AIDS training and performance improvement programmes, this commentary discusses promising practices for strengthening human resources for health through more efficient and effective training and learning programmes that avoid the same old traps. These promising practices include the following: Assessing performance gaps and opportunities before designing a training initiative; addressing performance factors other than skills and knowledge that health workers need to perform well; applying a "learning for performance" approach; standardizing curricula throughout a country; linking pre-service education, in-service training and professional associations; enhancing traditional education; strengthening human resources information systems to improve workforce planning, policies and management; applying technology to meet training needs.

Community case management (CCM) as applied to child survival is a strategy that enables trained community health workers or volunteers to assess, classify, treat and refer sick children who reside beyond the reach of fixed health facilities. The Nicaraguan Ministry of Health (MOH) and Save the Children trained and supported brigadistas (community health volunteers) in CCM to improve equitable access to treatment for pneumonia, diarrhoea and dysentery for children in remote areas. In this article, we examine the policy landscape and processes that influenced the adoption and implementation of CCM in Nicaragua. Contextual factors in the policy landscape that facilitated CCM included an international technical consensus supporting the strategy; the role of government in health care provision and commitment to reaching the poor; a history of community participation; the existence of community-based child survival strategies; the decentralization of implementation authority; internal MOH champions; and a credible catalyst organization. Challenges included scepticism about community-level cadres; resistance from health personnel; operational gaps in treatment norms and materials to support the strategy; resource constraints affecting service delivery; tensions around decentralization; and changes in administration. In order to capitalize on the opportunities and overcome the challenges that characterized the policy landscape, stakeholders pursued various efforts to support CCM including sparking interest, framing issues, monitoring and communicating results, ensuring support and cohesion among health personnel, supporting local adaptation, assuring credibility and ownership, joint problem solving, addressing sustainability and fostering learning. While delineated as separate efforts, these policy and implementation processes were dynamic and interactive in nature, balancing various tensions. Our qualitative analysis highlights the importance of supporting routine monitoring and documentation of these strategic operational policy and management issues vital for CCM success. We also demonstrate that while challenges to CCM adoption and implementation exist, they are not insurmountable. Community case management, child health, policy analysis, scaling up implementation, Nicaragua

Scaling-up is a managed process designed to mainstream an innovation through a project and generate broad impact. In the development cooperation context, the term ‘innovation’ does not refer to the invention of new technologies or products in the traditional sense. Instead, it involves changes within organisations and cooperation systems and in the way they deliver their services. The term ‘innovations’ might refer to strategies, approaches, methods or lessons learned that are new in a specific context. Significant changes need to be made to established routines within an area of social concern if these innovations are to be mainstreamed.

Health interventions vary substantially in the degree of effort required to implement them. To some extent this is apparent in their financial cost, but the nature and availability of non-financial resources is often of similar importance. In particular, human resource requirements are frequently a major constraint. We propose a conceptual framework for the analysis of interventions according to their degree of technical complexity; this complements the notion of institutional capacity in considering the feasibility of implementing an intervention. Interventions are categorized into four dimensions: characteristics of the basic intervention; characteristics of delivery; requirements on government capacity; and usage characteristics. The analysis of intervention complexity should lead to a better understanding of supply- and demand-side constraints to scaling up, indicate priorities for further research and development, and can point to potential areas for improvement of specific aspects of each intervention to close the gap between the complexity of an intervention and the capacity to implement it. The framework is illustrated using the examples of scaling up condom social marketing programmes, and the DOTS strategy for tuberculosis control in highly resource-constrained countries. The framework could be used as a tool for policy-makers, planners and programme managers when considering the expansion of existing projects or the introduction of new interventions. Intervention complexity thus complements the considerations of burden of disease, cost-effectiveness, affordability and political feasibility in health policy decision-making. Reducing the technical complexity of interventions will be crucial to meeting the health-related Millennium Development Goals.

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

Intervention complexity is a useful way to think about feasibility –It complements burden of disease, cost-effectiveness, and affordability considerations –It can help to identify R&D priorities to simplify interventions –It can guide decisions on how to implement interventions in specific settings Intervention complexity is a useful additional criterion for decision making on scaling-up health interventions

The USAID-funded flagship family planning service delivery project named Evidence to Action (E2A) worked from 2011 to 2021 to improve family planning and reproductive health for women and girls across seventeen nations in sub-Saharan Africa using a “scaling-up mindset.” The paper discusses three key lessons emerging from the project’s experience with applying ExpandNet’s systematic approach to scale up. The methodology uses ExpandNet/WHO’s scaling-up framework and guidance tools to design and implement pilot or demonstration projects in ways that look ahead to their future scale up; develop a scaling-up strategy with local stakeholders; and then strategically manage the scaling-up process. The paper describes how a scaling-up mindset was engendered, first within the project’s technical team in Washington and then how they subsequently sought to build capacity at the country level to support scale-up work throughout E2A’s portfolio of activities. The project worked with local multi-stakeholder resource teams, often led by government officials, to equip them to lead the scale-up of family planning and health system strengthening interventions. Examples from project experience in the Democratic Republic of the Congo, Kenya, Nigeria, and Uganda illustrating key concepts are discussed. E2A also established a community of practice on systematic approaches to scale up as a platform for sharing learning across a variety of technical agencies engaged in scale-up work and to create learning opportunities for interacting with thought leaders around critical scale-up issues.

Keywords Scaling up framework
· Implementation
· ExpandNet
· E2A
· Family planning
· Capacity building
· Country ownership
· Mindset

Small-scale pilot projects have demonstrated that integrated population, health and environment approaches can address the needs and rights of vulnerable communities. However, these and other types of health and development projects have rarely gone on to influence larger policy and programme development. ExpandNet, a network of health professionals working on scaling up, argues this is because projects are often not designed with future sustainability and scaling up in mind. Developing and implementing sustainable interventions that can be applied on a larger scale requires a different mindset and new approaches to small-scale/pilot testing. This paper shows how this new approach is being applied and the initial lessons from its use in the Health of People and Environment in the Lake Victoria Basin Project currently underway in Uganda and Kenya. Specific lessons that are emerging are: 1) ongoing, meaningful stakeholder engagement has significantly shaped the design and implementation, 2) multi-sectoral projects are complex and striving for simplicity in the interventins is challenging, and 3) projects that address a sharply felt need experience substantial pressure for scale up, even before their effectiveness is established. Implicit in this paper is the recommendation that other projects would also benefit from applying a scale-up perspective from the outset. © 2014 Reproductive Health Matters

Keywords: scaling up of services, pilot projects, health policy and programmes, population, health and environment, scale, development, WHO Strategic Approach, Kenya, Uganda

Since the visionary Alma Alta declaration of Health for All by the Year 2000 three decades ago, there has been much progress in improving the health of the world. There have also been many disappointments. The poor and much of sub-Saharan Africa and South Asia are still characterized by their high mortality rates. The failure to achieve past goals and likely failure to achieve future health goals like the Millennium Development Goals (MDGs) is frustrating because with each declaration, the international health community insists that those goals can be met. Unlike Winston Churchill, who in the darkest days of World War II, said, “Give us the tools and we will finish the job,” international health experts largely feel we have most of the tools needed to finish the job. If we have the tools to “finish the job,” then why haven’t we? And, what steps can be taken to “finish the job?” These are the two principle questions this report will address. For this report, we analyzed both successful and unsuccessful maternal and child health efforts to increase the accessibility of effective, mortality-reducing interventions. Although we drew upon the experiences of countries in Southeast Asia and Central and Latin America, our focus throughout the paper was on sub-Saharan Africa and South Asia, the regions with the most severe and challenging maternal and child health problems. The review of scaling up1 experiences in the last several decades has many lessons relevant for the future. Interventions that have been brought to scale have many things in common. The intervention is an easy to use, inexpensive, and effective product for a specific disease or condition that lends itself to a vertical, campaign-type of delivery system. We found examples of successful scaled-up efforts, but outside of the small pox and polio campaigns, few that were universally successful. Some countries achieved excellent coverage, others failed. More disturbing were instances in which successful scaling up of an intervention was achieved, but not sustained. The fact that health technologies are effectively scaled up and sustained in some countries but not in others suggests that factors external to the health technology determine the success of an intervention. A culling of less promising health technologies being championed for reducing maternal and child mortality is advisable since the requisite wherewithal to bring them all to scale is lacking now and in the foreseeable future, even assuming a much larger global commitment. It is also recommended that large scale research be conducted to determine the scaling up feasibility of promising, efficacious interventions which are unavailable to large populations.

While many Community-Driven Development (CDD) initiatives may be successful, their impact is often limited by their small scale. Building on past and ongoing work on CDD, this study addresses the fundamental question: how can CDD initiatives motivate and empower the greatest number of communities to take control of their own development? What are the key contextual factors, institutional arrangements, capacity elements and processes related to successful scaling up of CDD, and, conversely, what are the main constraints or limiting factors, in different contexts? Drawing upon recent literature and the findings from five case studies, key lessons on how best to stimulate, facilitate and support the scaling up of CDD in different situations, along with some major challenges, are highlighted. Lessons include the need for donors and supporters of CDD including governments to think of the process beyond the project, and of transformation or transition rather than exit. Donor push and community pull factors need to be balanced to prevent \"supply-driven demand-driven development\". Overall, capacity is pivotal to successful CDD and its successful scaling up over time. Capacity is more than simply resources -- it includes motivation and commitment which in turn requires appropriate incentives at all levels. Capacity development takes time and resources but is an essential upfront and ongoing investment, with the capacity and commitment of facilitators and local leaders being particularly important. A \"learning by doing\" culture - one that values adaptation, flexibility and openness to change -- needs to be fostered at all levels, with time horizons adjusted accordingly. The building of a library of well-documented context-specific experiences through good monitoring, evaluation and operational research will be useful in advocating for improvements in the contextual environment.

We want to pick up and expand on two sets of inter-related issues raised in the paper by Mangham and Hanson (2010): the importance of political commitment and of strategic management to scaling up. As the paper makes clear, these issues are integral to successful scaling up. Evidence on progress towards the Millennium Development Goals, for example, demonstrates the need for strong government leadership, whilst policy and strategic management is one of the five barriers recognized to constrain expansion of health interventions’ coverage. But, as the paper also shows, within scaling up debates little attention has so far been paid either to how to generate political commitment to scale up public health interventions, or to the nature of the strategic management also required to support this process. Yet there is (some) relevant health evidence, as well as relevant theory, around policy implementation (e.g. Hill and Hupe 2002) and innovation (Greenhalgh et al.2004), from which to draw useful insights. First, we look at political commitment. For low- and middle-income settings there is a relatively rich body of empirical work examining how policy agendas are set, including the transfer of policy ideas between international and national jurisdictions (Gilson and Raphaely 2008). This work critiques the idea that political will is the central determinant of successful policy change (Reich 1995). Instead, it shows how political commitment to a new policy or programme has to be actively created, essentially through advocacy. Examining maternal health policy experience, Shiffman (2007) highlights the importance of alliance building to consolidate influence, working with political entrepreneurs to get public health issues onto policy agendas, using credible measures to demonstrate the severity of the problem addressed through a new programme and avoid denial of its importance, organizing focusing events to publicize the issue and presenting policy makers with policy alternatives of proven effectiveness which show them the problem can be addressed. These sorts of advocacy efforts may also be important once an issue or programme is on the policy agenda, to secure sustained domestic budgetary commitments (Crichton 2008). When international actors seek to influence national policy agendas, they are, therefore, likely to be more effective when they work as advocates of change rather than adopting more coercive approaches (Walt et al.2004).

In their book, Putting Knowledge to Use, Glaser, Abelson, and Garrison undertake a large and important task. The intent of the book is (1) to review the extensive literature on knowledge use and the design of social change over the last decade, (2) to organize the research findings from multiple disciplines on these problems in a coherent, theoretical framework, and in so doing, (3) to create a new basis for understanding the complex, dynamic process of social learning and organizational change. The need to understand the process of using systematic social inquiry to solve actual social problems has been recognized for more than a decade. Argyris (1970, 1982), Rivlin (1971), Lindblom and Cohen (1979), Weiss (1977), Tornatzky (1980), and others have all identified the problems involved in translating new and relevant knowledge into existing social practice in order to revitalize the institutions, effectiveness, and creativity of our social order. The urgency of this need is underscored by the rapid proliferation of information and new knowledge made possible by social science research and technical advances in informa-tion processing and telecommunications (Bell, 1973, 1976). Yet, the potential for achieving effective utilization of this knowledge is limited by our ability to assess and apply the relevant knowledge to appropriate social tasks in timely, accurate fashion. Increasing our ability to do so requires a reformulation of the use of knowledge in social interaction. It is precisely this conceptual reformulation of the use of knowledge in contemporary social practice that the authors undertake in this volume. The design of the book represents a rational effort to decompose this large, complex problem into understandable components. In a brief, thoughtful introduction, the authors outline their conception of the task and scope of knowledge utilization and its generation of social change. Knowledge is broadly defined as facts, information,

Webinars on crosscutting issues. Agriculture and Rural Development (ARD) Working Group Climate Change Working Group Education Working Group Fragile States Working Group Health Working Group Monitoring and Evaluation (M&E) Working Group Nutrition Working Group Social Enterprise Scaling Up Working Group Youth Employment Working Group The Scaling Up Community of Practice (CoP) was founded six years ago by Larry Cooley and Johannes Linn. The purpose of the CoP is to provide a platform for knowledge exchange among experts and practitioners on approaches to scaling up development interventions, for developing partnerships, and for championing the idea that scaling up development impact is critical for achieving global development aspirations, such as the Sustainable Development Goals and climate change aspirations. Interest in scaling has greatly increased over these six years. The CoP has now more than 700 members from over 200 institutions (including bilateral and multilateral development organizations, operating NGOs, grant making foundations, universities and think tanks) and from many different sectoral and thematic areas of professional expertise. The CoP has organized four annual two-day in-person workshops in the Washington Metropolitan Area and currently operates nine sectoral and thematic Working Groups (education, health, agriculture, nutrition, social enterprises, youth employment, climate change, fragile states, and monitoring and evaluation) each of which meets virtually three times a year, as well as in-person during past CoP workshops. The CoP has issued eighteen Newsletters to date, sharing news about scaling up research and practice from the Working Groups, from CoP members, and from the broader development community. Three years ago, an Executive Committee was formed from among the membership. Management Systems International (MSI) has generously provided administrative and logistical support since the establishment of the CoP. There is strong support among the membership for the continuation and strengthening of the CoP. The CoP receives financial and in-kind support from a number of organizations and individuals, which has allowed it to host its annual workshop, invite and support southern participants, and develop and support a website.

Background
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.

Participants at the workshops made it clear that appropriate technologies and approaches are available that can lead to the production of more food by poor farmer groups in marginal environments without creating dependence on external inputs and without damaging the natural resource base.
The recommendations and conclusions give guidelines on how to proceed with scaling up processes.

In many respects, the so-called Graduation Program has been a roaring success: it’s the only intervention proven to lift people out of extreme poverty. With food parcels, life skills classes and two years of asset transfers, it’s a complete package. Almost 100 countries have experimented with it, providing a rock-solid evidence base. So why isn’t it national policy across the world? The biggest determinant of whether an intervention will succeed at a huge scale, changing the lives of millions rather than dozens or hundreds or even thousands, is not whether it works, but whether it was designed in a way that made it suitable for scale in the first place. The path from developing a program that works to helping huge numbers of people is a long one, often taking 10 to 15 years. Organisations that don’t anticipate the difficulties will develop programs with features that make them inherently difficult or even impossible to scale up. The Graduation Program, for example, is expensive. And now governments that want to implement it are trying to cut costs — but they don’t know what to cut and what to keep without losing the effects. For reasons like this, success on a small scale is no indication, let alone a guarantee, of success on the big stage. Only interventions that are relatively simple, clearly better than the alternatives and not reliant on unique conditions are likely to scale well. But it can be done. The secret is to plan for that long journey right at the beginning and to design something that will not just survive, but thrive as it gets bigger. So how do you do that?

Q&A with Karen Levy of Evidence Action, the NGO that delivers solutions to hundreds of millions of people.

In wealthy and developing countries alike, service providers are under pressure to reduce costs, improve social outcomes and explain why it has proven so difficult to accelerate the spread of best practices. In 2003, the MacArthur Foundation gave one of its famous grants to an unusual recipient: a private company called Management Systems International (MSI). Their mission? To develop and test a framework to improve the scaling up process. That grant turned out to be the first of five. MSI was founded by Larry Cooley, who has worked in more than 50 countries in strategic management, public sector reform and international development. That includes serving as an advisor to cabinet officials in more than a dozen countries, and overseeing a nine-year effort to rebuild Iraqi public administration. Cooley currently curates a global community of practice on scaling up development outcomes and serves as the scaling advisor for the MacArthur Foundation’s 100&Change grant, which recently awarded $100 million to The Sesame Workshop to bring their early childhood intervention to Syrian refugees. He spoke to Apolitical about what he’s learned over nearly three decades grappling with the question of scale. You’ve been applying your framework for over a decade. What’s the most important thing you’ve learned? You can’t worry about scaling second — you have to worry about it right at the beginning. There’s a model that I used for a long time that talked about three steps: effectiveness, efficiency, expansion. First build something that works, then figure out how to produce it efficiently, and then come up with a plan to spread it. And that made perfectly good sense to me then — but I now think it’s wrong. \"If you don’t worry about how it will spread at the very beginning, you will develop something inherently difficult to scale\" If you don’t worry about how it will spread at the very beginning, you will develop something with features that make it inherently either impossible or difficult to scale. This is a very difficult row to hoe, psychologically, because it means you have to plan for scale and nevertheless remain sceptical about whether the thing you’re working on should be scaled. Because there’s another problem: people fall in love with their pilots. So as soon as they start down the road, they’re not only planning for scale but that’s their success standard. Then they’re too quick on the draw: they’re anxious to scale prior to the time that they should. \"People fall in love with their pilots\" And, if you look at the amount of time it takes for things to go from a good idea, even a great idea, to a scaled up solution, the mode is about 15 years. That’s much longer than the time horizon of most interveners. Figuring out strategies that keep things in motion and commitments in place for as long as it takes to see an innovation all the way through the system is still developing as an art form.

Implementation science, or research to translate evidence-based findings into common practice, is quickly becoming an integral component of many global health programs. This novel approach to health research addresses knowledge gaps between innovations such as vaccines, drugs and care strategies and their delivery to patients and communities. Studies continue to show, for example, that the risk of HIV transmission can be reduced through condom use, yet infection rates continue to rise in some regions of the world. Research on implementation identifies barriers to proven interventions and facilitates the creation of local strategies to overcome them. The concept of translating research into practice and policy was discussed in-depth at a recent two-day implementation and dissemination conference sponsored by NIH and a subsequent Fogarty satellite meeting focused on implementation science in the global health context. "It's an area ripe for exploration," said NIH Director Dr. Francis Collins. "Implementation science is part of our mission." Collins says it's important to ensure that research reaches communities in need, as well as conducting research to determine what works and what doesn't in the real world. The NIH conference, now in its third year, drew approximately 630 attendees and focused on methods and measures. Over 50 presenters showcased research and health care delivery projects addressing a wide range of issues, including war-related trauma, stroke care, community mental health, homelessness, STD prevention, family planning and school-based interventions. "Research must combine relevance to decision-making," said Dr. Julio Frenk, Dean of the Harvard School of Public Health, drawing from his experiences establishing highly successful, large-scale health programs in his native Mexico. "Excellence and relevance can have a fruitful relationship through knowledge translation." Implementation science is of particular importance to global health as the concept addresses hard questions such as how best to translate new findings into practice in different cultural settings, how to reduce the fragmenting of health systems into programs centered on a single disease - particularly in low-resource settings - and why health interventions lose efficacy over time or sometimes display unintended effects. Lynn Freedman, professor of clinical population and family health at Columbia University, warned of an additional challenge, namely, the "dangerous fallacy" that technical input, political will and money will amount to functioning services. She used the analogy (see Figure 1: Chart of Problems with Varying Levels of Complexity) of following a recipe, launching a rocket to the moon and raising a child as three problems with different levels of complexity. Implementation science falls into the most challenging category.

Key messages
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

The literature around scaling strategies for nonprofits relevant to grantmakers is vast. Our literature review included reading and reviewing every piece of work in the Social Impact Exchange’s 175 item online database, plus selected reviews of other published content from many of the Exchange’s Knowledge Working Group’s member organizations’ websites and data repositories. (The Knowledge Working Group and its members are detailed in Appendix B. More detail on our methodology is in Appendix D.) This executive summary offers our overall observations about the state of knowledge from these sources and some of the themes that emerged. The Majority of the Scaling Literature is Written for Practitioners, Not Funders. A majority of the existing literature in our database review is written for a broad nonprofit audience. As a result, the knowledge base on scaling is mostly focused on providing nonprofit leaders, practitioners, program directors and managers with the information they need to undertake a scaling initiative, not on discussing the funder’s role in supporting scaling initiatives. Still, There are Significant Resources Relevant to Funders. Approximately one third of all the literature in the database addresses roles of the funder. Of that third, the resources that were written specifically for grantmakers or funders are generally written by foundations, or were commissioned by foundations and written by consulting firms, evaluation firms, and intermediaries. Our editorial filter for this review was to include the materials we judged to be most useful to funders and grantmakers interested in supporting scaling initiatives. Therefore, this review is not a comprehensive listing of all content on scaling, but an editorialized selection, based on pieces we believe reveal fundamental, generalizable frameworks, theories and lessons for grantmakers that are communicated in effective, readable ways. For this reason, this review does not include many purely academic studies. Evolution of Literature from Scaling Organizations, to Scaling Impact: The earlier literature on scaling focuses on scaling organizations – for example, the literature in the Exchange’s database dates to 1994, with a report published by Public/Private Ventures on the strategy of replicating social programs. However, in the last decade or so, the literature has shifted to include a broader definition of scale – moving away from the concept of scaling as organizational growth and towards the concept of scaling impact, or the outcomes the organization has generated beyond just the organization itself.

In this fourth post in our series on pathways to scale social accountability, we discuss context. We argue that context influences which pathways to scale are more likely to be effective at a particular point in time. We believe that, for selecting the preferred pathway, there are four especially important aspects/dimensions of context that are worth exploring further. We highlight these four factors in the table and discuss them at greater length below.

Scale is a complex change process that is often misunderstood. We need to better understand what it looks like in practice, whether, how, and under what conditions (by whom, where, when) social accountability might be scaled up. Better understanding pathways to scale is the theme of this 5-part blog series.

This is the last post of a 5-part series about scale in social accountability, and more broadly the transparency, participation, and accountability (TPA) sector. We started by discussing what scale looks like in the real world. We explained how, in our view, there is no single pathway to scale, or quoting Byrne (2013: 1) “different mechanisms [or paths can] produce different outcomes and… [the] same outcome… the search for the — that is to say universal, always and everywhere, nomothetic — model that fits the data” is in vain. Ultimately, no single model fits the data. We then presented multiple paths through which scale up may happen (resonance, resistance, and best practice). Lastly, we focused on a handful of contextual factors that may help practitioners to understand under which conditions each path might be a better bet. In this post, we argue that politics in the transparency, participation, and accountability field happen in time. There is more to politics and change in time than black and white debates about short and long term support. Temporal contexts are about stability and change, timing time horizons, sequences, feedback loops, gradualism vs. shock therapies, etc. They provide a concrete way to to grapple with how agents contribute to scale through different pathways in complex, uncertain systems that make up a world of greys and mixed results — i.e. the world of much TPA work.

The Commission on Macroeconomics and Health recommended a significant expansion in funding for health interventions in poor countries. However, there are a range of constraints to expanding access to health services: As well as an absolute lack of resources, access to health interventions is hindered by problems of demand, weak service delivery systems, policies at the health and cross-sectoral levels, and constraints related to governance, corruption and geography. This special issue is devoted to analysis of the nature and intensity of these constraints, and how they can best be overcome.

Adopting new practices in health on a large scale requires systematic approaches to planning, implementation, and follow-up; and often calls for profound and lasting changes in health systems. Any systematic approach must include addressing the policy dimensions of scaling up. Without attention to the policies that underlie health systems and health services, the scale-up of promising pilot projects is not likely to succeed and be sustained. Interest in scale-up has grown in recent years because of an increased urgency to rapidly expand effective interventions to improve the health of mothers, children, and families, particularly the poor and underserved. This paper focuses on efforts to scale up interventions in family planning, reproductive health, and maternal, neonatal, and child health in developing countries. It defines “scale-up” and describes some of the frameworks and approaches to scaling up found in recent health literature and how they address policy. The paper also reviews the experience of selected organizations in scaling up best practices and how they have addressed policy issues. Often, frameworks for scaling up mention policies only in passing, as if addressing policy were a single step. Few scale-up frameworks and methodologies offer systematic guidance on identifying and addressing policy issues at each phase of scale-up, from planning through implementation, and on monitoring and evaluation for sustainability. Similarly, many programs tend to focus more on expansion than on institutionalization of new practices. As a result, program planners may fail to pay attention to policy throughout the health system, which is essential for programs to be successfully established and sustained. “Policy” should be understood as more than a national law or health policy that supports a program or intervention. Operational policies are the rules, regulations, guidelines, and administrative norms that governments use to translate national laws and policies into programs and services. The policy process encompasses decisions made at a national or decentralized level (including funding decisions) that affect whether and how services are delivered. Thus, attention must be paid to policies at multiple levels of the health system and over time to ensure sustainable scale-up. A supportive policy environment will facilitate the scale-up of health interventions. This paper does not replace the valuable guides that are available for scaling up health innovations. Rather, it focuses on lessons learned related to policy implementation associated with scaling up and outlines key actions to ensure supportive policies, regardless of the scale-up model or approach used.

To achieve the greatest possible improvement in family planning (FP) and maternal, neonatal, and child health (MNCH) outcomes, successful interventions, practices, and approaches must be \"scaled up,\" that is, implemented on a larger scale and incorporated into the laws, policies, and structures that govern health systems. In recent years, growing recognition of the importance of scale-up has led to intensified efforts to identify and scale up best practices in FP/MNCH and improve scale-up processes. Policy development and implementation are central to successful and sustainable scale-up. This package of materials presents a programming approach designed to help countries advance the integration and measurement of policy development and implementation into the scale-up of FP/MNCH interventions and best practices. The approach provides planners and implementers with initial guidance and suggestions on how to systematically address policy development and implementation as they scale up FP/MNCH programs

At the Gleneagles Summit in 2005, leaders of the G8 group of nations committed to increase aid to poor nations by $50 billion per year. During the same year, in a meeting in Paris, donors promised to coordinate their interventions for more eff ective delivery. Th ese commitments are now often referred to as the promise of donors to “scale up aid.” Increasing aid fl ows and improving coordination are indeed important goals and, in fact, goals that donors seem to have trouble meeting. Th e international donor community met this fall in Accra and will meet in Doha in November 2008 to review progress with this aspect of scaling up aid, and it is hoped that they will recommit to meet the ambitious targets set three years ago. Scaling up aid is only one of the challenges that donors face. A more important challenge is to “scale up through aid,” meaning that aid fl ows should not merely support short-lived, one-time and partial development interventions—pilot projects, short-term technical assistance, programs that only address part of the problem, but leave major bottlenecks unaddressed—but should support projects, programs and policies that scale up successful interventions in a country, region or globally to reach the entire target population. Scaling up means that programs are long-term and sustained and that external support is aligned with country needs and deals comprehensively with the development challenges—often by working in partnership with other donors and pooling resources. Th is is the scaling up challenge that donors should address head-on, but so far have not. Th is policy brief reports on the fi ndings of an in-depth review of the literature and practice of scaling up development interventions and focuses on the role that aid donors can play in supporting scaling up for eff ective development. It stresses that successful scaling up with external assistance means that donor agencies need to: work with a vision and leadership; help create the political constituencies for large-scale implementation; create linkages among project, program and policy interventions; strengthen the institutional capacity of the implementing entities; provide for eff ective incentives and accountabilities of their own staff and management; work together with each other; monitor and evaluate the progress of programs with special attention to the scaling up dimension; and fi nally make sure they focus on eff ective preparation and fl exible implementation of the scaling up process. While this is a long-term agenda, donors can take a few practical steps right away that will provide a basis for a more ambitious eff ort over time.

Scaling up of development interventions is much debated today as a way to improve their impact and effectiveness. Based on a review of scaling up literature and practice, this paper develops a framework for the key dynamics that allow the scaling up process to happen. The authors explore the possible approaches and paths to scaling up, the drivers of expansion and of replication, the space that has to be created for interventions to grow, and the role of evaluation and of careful planning and implementation. They draw a number of lessons for the development analyst and practitioner. More than anything else, scaling up is about political and organizational leadership, about vision, values and mindset, and about incentives and accountability—all oriented to make scaling up a central element of individual, institutional, national and international development efforts. The paper concludes by highlighting some implications for aid and aid donors.

Scaling up of development interventions is much debated today as a way to improve their impact and effectiveness. Based on a review of scaling up literature and practice, this paper develops a framework for the key dynamics that allow the scaling up process to happen. The authors explore the possible approaches and paths to scaling up, the drivers of expansion and of replication, the space that has to be created for interventions to grow, and the role of evaluation and of careful planning and implementation. They draw a number of lessons for the development analyst and practitioner. More than anything else, scaling up is about political and organizational leadership, about vision, values and mindset, and about incentives and accountability—all oriented to make scaling up a central element of individual, institutional, national and international development efforts. The paper concludes by highlighting some implications for aid and aid donors.

This report provides a framework for understanding the processes of innovation, dissemination, and knowledge utilization, and it reviews the relevant literature in education and other fields of practice within this framework. Dissemination and utilization (D&U) is viewed as a transfer of messages by various media between resource systems and users. Major sections analyze characteristics of individuals and organizations which inhibit or facilitate this transfer. The process is interpreted at four levels; the individual, the interpersonal, the organization , and the social system. Additional chapters deal specifically with specialized "linking" roles between resource and user, types of messages, types of media, and phase models of the process. Major conclusions from the review are as follows. The principle models of D & U employed by most authors can be grouped under three perspectives identified as ( 1 ) "Research, Development, and Diffusion", ( 2 ) "Social Interaction", and ( 3 ) "Problem Solving". Each of these three viewpoints contributes significantly to our understanding of the total D&U process. They can be brought together in a "linkage model" which incorporates important features of all three. Linkage is seen as a series of two - way interaction processes which connect user systems with various resource systems including basic and applied research, development, and practice. Senders and receivers can achieve successful linkage only if they exchange messages in two - way interaction and continuously make the effort to simulate each other's problem solving behavior. Hence, the resource systems must appreciate the user's internal needs and problem solving patterns, and the user, in turn, must be able to appreciate the invention, solution formulation and evaluation processes of the resource systems. This type of collaborative interaction will not only make solutions more relevant and effective but will build relationships of trust, mutual perceptions by user and resource persons that the other is truly concerned, will listen, and will be able to provide useful information. These trust relations over time can become channels for the rapid, effective, and efficient transfer of information. Effective knowledge utilization also requires a degree of division of labor, coordination and collaboration throughout the social system. The role of government should be to monitor the "natural" knowledge flow system and develop means to support, facilitate, and coordinate linkage activities so that the total system can function more effectively.

Soon after the ink dried on world leaders’ ambitious commitments in 2015 to meet the Sustainable Development Goals, thoughtful observers pointed out that the goals could not be achieved by simply ramping up the best approaches known then. New solutions — better, faster or more affordable — would have to be found and applied widely across Africa, Asia, Latin America, as well as in high-income countries. The importance of innovation in international development, already a familiar refrain for decades, has received even more attention since the adoption of the SDGs. But while global dialogue about innovation has proselytized in terms of the power of doing things differently, in most sectors, we remain seemingly stuck in an endless cycle of pilots, hype and showcases. And we often have little to show in terms of sustained gains and improved access to services for the poorest and most vulnerable. Why the continued cycle of discovery, overhype and disappointment? Current thinking suggests either a market failure centered on access to financing (“we need more money to scale”) or a positioning breakdown (“social entrepreneurs can only take things so far, and government is dropping the ball”). Based on new research, we suggest a more fundamental disconnect in the current work to leverage innovation to drive development outcomes: the continued fetishization of the breakthrough “innovation” as the most important unit of analysis.

Over the past generation, globally, there have been enormous gains in health and well-being. In large part this has been a consequence of improvements in economic conditions. And there have been synergistic effects across social sectors; for example, improvements in women’s level of education and literacy have had further benefits with regard to child health, nutritional status and well-being. But specific program efforts in health have also made an important contribution. Primary healthcare programs and services have been developed and in many important instances are reaching a large proportion of those who can benefit from them and have made an important contribution to improved population health status. Immunization is a case in point. Nevertheless there are also instances of initiatives or program efforts that develop momentum and continue, drawing considerable resources, despite not making the impact they were intended to. There is a failure to acknowledge and remediate. This phenomenon of dysfunctional persistence of efforts that in fact are not delivering is seen across human endeavors. Most people in the United States are aware of the DARE anti-drugs program which has been running for over 30 years and, at its peak, was active in 3/4s of all school districts in the country. Billions have been spent on the program and it continues to chug along despite rigorous evaluations that have systematically demonstrated that it’s not been working (Lynam 1999, Birkeland 2005). There is now a well-developed literature on the phenomenon of escalation, the process of increasing commitment to a failing course of action (Ross and Staw 1987, 1997; Brockner 1992; Arkes and Blumer 1985; and others). But beyond factors identified in this literature from other sectors, there are also dynamics more specific to global health and development assistance. This discussion paper presents results of an initial effort to investigate this set of issues. It is intended as part of a broader ongoing effort to better characterize the problem, identify solutions and galvanize efforts for improved effectiveness. This paper presents findings of a series of interviews with global health leaders with substantial on the-ground experience. With input from an advisory group, a list was drawn up consisting of 30 potential interviewees. The general criteria for selection included: Anticipated depth of insight into the questions of interest, Breadth and depth of experience, and Diversity across the sample with regard to: geography of program experience (focusing mainly on low-income countries), global health content areas, and institutional role (ministry of health, donor agency, technical assistance agency, evaluator).

Scaling-up community mobilization means expanding the impact of a successful mobilization effort beyond a single or limited number of communities to the regional, national, or even multinational level. While the appeal of scaling-up is obvious, the challenge is to do so without diminishing the quality of the original effort. Experience over the last decade is beginning to show that community mobilization approaches can be scaled up. This chapter will look at some of these experiences and will lay out steps to help you scale up successful community mobilization approaches. Programs achieve scale either by starting out at scale (or very quickly going to scale) or through incremental efforts to expand coverage.1 Programs typically scale up in one of five major ways: Planned Expansion: a steady process of expanding the number of sites for a particular program model once it has been pilot-tested and refined. 2 Explosion: sudden implementation of a large-scale program or intervention, without any cultivation of policy support or gradual organizational development prior to implementation. Association: expanding program size and coverage through common efforts and alliances among a network of organizations. Grafting: adding a new young adult reproductive health program, for example, to an already existing program. Diffusion: other organizations learning about approaches through access to materials and case studies and replicating the approach. Without significant uptake—the degree to which other significant development actors (e.g., NGOs, community-based groups, bilateral and multilateral agencies, host governments) adopt and adapt methodologies— scale cannot be reached. Uptake is significantly different from replication in that the former involves adaptation of strategies or methodologies to fit varying program contexts. In order to achieve substantial uptake, an organization needs to:

The Humanitarian Innovation Guide is a growing online resource to help individuals and organisations find their starting point and navigate the humanitarian innovation journey.

Background:
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.

This call is a result of the scalingXchange—a virtual gathering of researchers and innovators from across the Global South to learn from scaling experiences and how funders and development agencies can better support scaling efforts.

This evaluation/ strategic review employs a mixed-methods design which supports the interconnected components: an organisational review, studies of grantee perceptions and IDRC’s external position, and a series of thematic case studies. The evaluation developed a ‘scaling pathway’ conceptual framework. It looked for three types of policy outcomes, as defined by IDRC’s Policy and Evaluation division: (1) Expanded policy capacities of external actors, including for scaling, (2) Informed policy dialogues and decision-making processes, and (3) Contributions to policy implementation or change. IDRC’s Scaling Science approach focuses on scaling impact rather than actions.

Given the large-scale problem of reducing rural poverty that it is mandated to address and the limited resources available from official development assistance (ODA), IFAD needs to increase the impact of every dollar it invests in agriculture and rural development. For this reason, scaling up the results of successful development initiatives is an overarching priority that directly supports the achievement of IFAD’s mandate.

What is this module about? Learn about scaling up, its basic concepts and why it is important for organisations like IFAD working in agriculture and rural development. Why do I need to know this? Understanding scaling up will help you to ensure that your country programmes have a wide reach and long-lasting impact.

IMAGO was founded in 2014 by Isabel Guerrero and Zachary Green to close the missing middle in development. Our goal was to help grassroots projects scale the impact of their effective development solutions through participatory, and human-centered approaches. In biology IMAGO is the last stage of the growth process in an insect, when it attains maturity and finds its wings. IMAGO Global Grassroots helps its clients accelerate the process of finding their wings so they can develop their inborn potential and scale their impact.

This guide is based on the recognition that change is inevitable for survival and that directed and planned change has a much greater chance of success than ad hoc attempts to introduce new practices. Everyone working to improve health, including donors, researchers, technical experts, service providers and advocates at the global, national, district, community and family level is in the business of fostering, leading or implementing change. But not everyone involved in this work has a clear pathway that links proven change practices with evidence-based clinical and programmatic innovations. Purpose of the Guide Successful change is not an end in itself. Rather, it is a means of improving the availability and quality of services, expanding utilization and, ultimately, improving health outcomes. This guide links effective change practices with proven clinical and programmatic practices to achieve results by: Describing principles fundamental to effective change. Increasing awareness of proven approaches to effective change. Providing “how-to” steps for successful change including scale-up. Describing key challenges of scaling up and recommending strategies, tools or approaches for meeting those challenges. Offering cases that show how the steps have been implemented in real-life situations. Audience for the Guide This guide is for policy-makers, programme managers, operations researchers or other health professionals who want to bring about change in a health practice or set of practices. Changes in health practices can originate at different levels. Sometimes an evidence-based practice is introduced nationally or regionally to resolve a widespread public health concern. For example, a Minister of Health or donor might initiate the provision of insecticide-treated bed nets to reduce infant deaths from malaria or the provision of MgSO4 to prevent deaths from eclampsia. But sometimes the change “bubbles up” from the staff of a health facility seeking to address a service delivery challenge. There are many examples of hospital directors who introduced proven practices to reduce infection rates or clinic nurses who mobilized their staff to improve counselling to increase family planning acceptors. A range of groups can act together as a Change Coordination Team to support change, including international, regional and country members of the IBP Consortium; representatives from Ministries of Health and other government ministries; non-governmental organizations (NGOs) and faith-based organizations (FBOs); regional and country WHO, UNFPA, and IPPF offices; USAID missions; and regional and country offices of USAID cooperating agencies and other donors and decision makers. Active players in a successful change process often include representatives of national, regional or institutional organizations who are in a position to support the change as part of the coordination team, as well as those who are implementing the change on the ground at a programme level, service delivery site or in the community

To achieve population-wide health improvement, public health interventions found effective in selected samples need to be ‘scaled up’ and implemented more widely. The pathways through which interventions are scaled up are not well characterised. The aim of this paper is to identify examples of public health interventions which have been scaled up and to develop a conceptual framework which quantifies and describes this process. Methods A multi-stage international literature search was undertaken to identify examples of public health interventions in high income countries that have been scaled up or implemented at scale. Initial abstract review identified articles which met all the criteria of being a: 1) public health intervention; 2) chronic disease prevention focus; 3) program delivered at a wide geographical scale (state, national or international). Interventions were reviewed and coded into a conceptual framework pathway to document their scaling up process. For each program, an in-depth review of the identified articles was undertaken along with a broad internet based search to determine the outcomes of the dissemination process. A conceptual framework of scaling up pathways was developed that involved four stages (development, efficacy testing, real world trial and dissemination) to which the 40 programs were mapped. Results The search identified 40 public health interventions that showed evidence of being scaled up. Four pathways were identified to capture the different scaling up trajectories taken which included: ‘Type I – Comprehensive’ (55%) which passed through all four stages, ‘Type II – Efficacy omitters’ (5%) which did not conduct efficacy testing, ‘Type III – Trial omitters’ (25%) which did not conduct a real world trial, and ‘Type IV – At scale dissemination’ (15%) which skipped both efficacy testing and a real world trial. Conclusions This is the first study to classify and quantify the potential pathways through which public health interventions in high income countries are scaled up to reach the broader population. Mapping these pathways not only demonstrates the different trajectories that occur in scaling up public health interventions, but also allows the variation across scaling up pathways to be classified. The policy and practice determinants leading to each pathway remain for future study, especially to identify the conditions under which efficacy and replication stages are missing.

ABOUT SCALING PATHWAYS
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.

This Guide was created as a resource for the adaptation and scale up of a country's unique action plan to address violence against children. It can be used as activities to end violence against children are selected, implemented, adapted, and scaled. National commitments of countries eager to end violence against children have grown rapidly since the UN Convention on the Rights of the Child in 1989. The pandemic of violence against children is one that the world continues to confront in a focused and coordinated way. In 2016, the multi-agency, multi-sectoral technical package ‘INSPIRE’ was published. INSPIRE represents a select group of strategies based on the best available evidence to help countries and communities intensify their focus on the prevention programs and services with the greatest potential to reduce violence against children. The INSPIRE strategies encompass: Implementation and enforcement of laws Norms and values Safe environments Parent and caregiver support Income and economic strengthening Response and support services Education and life skills. Also in that year, the Global Partnership to End Violence Against Children was established with the country “Pathfinder” model at the center of its strategy. Pathfinding countries are those whose government leaders commit to comprehensive action to end all forms of violence against children. The Pathfinder model has the potential to serve as an ideal platform for coordinated national action to scale implementation of the INSPIRE strategies. This Guide’s subject matter is on the adaptation and scale up of the INSPIRE approach. As each country’s approach to violence against children is unique to its needs, priorities, and capacities, the Guide is designed to highlight the decisions that need to be made in the adaptation and scaling up of the multi-sectoral INSPIRE approach. It then provides simple tools for collecting and analyzing the information needed to take action. This Guide is a practical and flexible tool to help policy makers and practitioners make decisions as they select, adapt and implement activities to prevent and respond to violence against children. It is our hope that this will be a significant next step towards INSPIRE’s goal of improving the lives of children and their families. This Guide is a reference that can be used as priority activities to end violence against children are selected and implemented. While neither adaptation or scale up are new ideas to most readers, we often approach them without adequate planning. We may make adaptation decisions without anticipating shifts in resources, capacities, mandates, policies, or timelines. Often, we decide to expand activities to new sites assuming they will take root without considering long-term sustainability. We can avoid this by developing a structured adaptation and scale-up strategy. This will support our country’s action plan to end violence against children by establishing goals appropriate to local conditions; setting benchmarks to know if we are meeting our objectives; and creating conditions that help us broaden and sustain success.

More and more organisations are talking about scaling. But what is it, and what does it mean for our work? This animation explains a new approach that focuses on scaling our impact, rather than our actions, and how you may recognise it in your work.

Participants at the workshops made it clear that appropriate technologies and approaches are available that can lead to the production of more food by poor farmer groups in marginal environments without creating dependence on external inputs and without damaging the natural resource base. The recommendations and conclusions give guidelines on how to proceed with scaling up processes. agriculture, capacity building, community participation, institutional aspects, monitoring, partnerships, replicability, research, rural development, sdicap, sdiman, small-scale activities

Introduction:
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 objective of this report is to assess the usefulness of providing guidance for scaling up good practices in core ARD business lines, and to test the prospects for doing so. The output of the document is a guide for a systematic discussion on scaling up of Competitive Grant Schemes (CGSs) for agricultural research and extension at key decision points during the life of an ARD project. This report addresses the other end of the state-of-practice spectrum - good practices and beyond. The preparation of this report entailed five main activities: An overview of scaling up concepts and approaches; the selection of a particular sub-area within one of ARD's core business lines - scaling up CGS for agricultural research and extension; application of the IFAD/Brookings framing questions to five World Bank projects that were identified as addressing that business line - using information provided by the project's task team leaders (TTLs) or other member of the project team; the development of sub-area specific guidance for a systematic discussion on scaling up based on the findings from a series of five case studies; and validation of the scaling up guidance for CGSs for agricultural research and extension by World Bank practitioners and other internal consultations.

In Chapter 2, we listed some 27 recommendations arising out of the multipronged survey we conducted, the literature search and our deliberations. They add up to a strong endorsement of the case for piloting new policy initiatives wherever practicable. And they provide enthusiastic support for the fact that the practice is now being embraced so widely across government. There is no doubt that, costly and time consuming as some pilots are, the overall benefits they provide to good governance far outweigh their disadvantages. Naturally, they fulfil an important defensive role in guarding against the inclusion of embarrassing, often expensive and preventable mistakes into new policy initiatives. But they play a highly constructive role in promoting innovation (via explicit, small-scale experiments and trials), and in helping to fine-tune policies and their delivery mechanisms in advance of their national roll-out. In short, policy pilots have become an indispensable tool of modern government. A large part of this report deals with the sorts of practical considerations that either enhance or diminish the optimal use of policy piloting in Britain. In sum they suggest that, excellent though some practice already is, there is still a long way to go before this will be uniformly true across all administrations, departments or, for that matter, across all pilots within any department. A great deal of practice still falls far short of its potential, and by no means all the obstacles to good practice will be simple to surmount. Some, such as the deep-seated suspicion in some quarters of RCTs, even in circumstances when they would seem to be an ideal mechanism, will take time to overcome, but surely will be. Others, such as the routine assumption that any new policy initiative must necessarily be introduced at the earliest possible moment, even when a small delay will help to ensure it is wellhoned, will probably take more of a culture change to rectify. On the other hand, British policy pilots have been gaining in sophistication in recent years, both in their methodology and in their analysis, and many debilitating notions of what used to be considered possible or desirable have demonstrably been dispersed. We were particularly taken with the enthusiasm we encountered both among Ministers and senior civil servants who had experienced recent pilots in action. They had generally been convinced not only of the immense value of piloting in general, but – perhaps more importantly – of the desirability of more experimentation within policy pilots, designed explicitly to try out different models to achieve particular ends. Britain still has lessons to learn from abroad, particularly about the methodology of piloting and its role in overall evaluation strategies. While our political and legislative frameworks remain less conducive to an optimal use of policy piloting than in, say, the US, great strides have been made in the past few years in both these respects.

CGIAR has been working to improve food and nutritional security and reduce poverty in developing countries through research and development activities on efficient, safe, and sustainable livestock use. However, translating research outputs into products that can be adopted at scale has been a significant challenge for researchers in ILRI and other CGIAR centres. To address this, ILRI's Impact at Scale (I@S) program has curated and synthesized a set of scaling tools and approaches to help researchers address this enduring challenge in their work. ILRI’s evolving I@S approach, initially summarized in the ‘scaling better, together’ scaling framework, is a modular approach with three ‘tracks’: light, standard, and an extended track. The light track builds on an adapted version of the Scaling Scan tool by the Public-Private Partnerships (PPP) Lab and the International Maize and Wheat Improvement Center (CIMMYT), and the Agricultural Scalability Assessment Tool (ASAT) by the United States Agency for International Development (USAID). It leads to an agreed scaling ambition from a stakeholder consultative process, a review of the scaling ambition against ten Scaling Ingredients, and identifying potential opportunities and threats to reaching the stated Scaling Ambition.

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.

China’s family planning programme ranks as history’s most intensive effort to control national population growth. While some have lauded China’s effort to limit births as a fundamental part of its sustainable development goals, the population policy has also generated much international criticism. A long-overdue reform has begun to focus the family planning programme on client needs, informed choice of contraceptives, and better quality services. Partly inspired by the International Conference on Population and Development in 1994, the reform began as a pilot project in six counties and is now a blueprint for reorienting the national family planning programme. This chapter reviews the process by which a small innovative pilot project was scaled up into a national reform effort and the lessons learned about scaling up sensitive but needed innovation in a difficult political environment. These lessons relate to the importance of local ownership, adapting concepts to make them locally meaningful, careful choice of pilot sites to ensure success, mobilizing political networks, cultivating and educating allies in senior leadership positions, strategic use of donor funding and technical assistance, and the willingness to transfer project management to the next generation of leaders.

For solutions to get to scale, we need strong entrepreneurs who can build on existing breakthrough ideas, rather than creating entirely new ones. The shortage of high-quality impact investment opportunities with the potential to generate both financial and social returns remains a critical challenge for the industry. There is a growing sense that the profile of enterprises investors would like to see—particularly in terms of quality leadership teams and business models—is not reflected in the pipeline of enterprises actually emerging. Meanwhile, philanthropic and aid donors supporting this sector are increasingly frustrated, as examples of large-scale impact remain few and far between.

The scaling up of promising health innovations in
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.

This paper has identified and described ten crosscutting topics about scaling in international development that merit further exploration. They were selected drawing on the discussions that took place at the CoP Annual Meetings; in some cases by explicit mention, and in other cases as underlying issues. These issues are based on the author’s subjective assessment of their importance, interest, or where further exploration might be most beneficial to CoP members and scaling practitioners writ large. No claim is being made that these topics are the ten most important to scaling at this moment, or that other topics are not important. Beyond simply identifying each topic, this report has attempted to describe the parameters of each issue and suggest what a further exploration and investigation of each theme might look like. In the course of doing so, it became apparent how in several cases the issues themselves are so knotty and entangled that our recommendation for a first step is to get some definitional clarity, and clearly identify the different opinions on the topic. The prime example is the cluster of issues around Scaling, Systems Change and Complexity. At a minimum, we hope that the topics identified resonate with enough CoP members that they, and hopefully other readers, are motivated to explore them further, and that the description is sufficient to serve as a basis for that exploration. Such exploration might begin with CoP workshops, webinars, or debates about these issues. More ambitious would be for the CoP or its members to write or commission papers on the issues discussed herein. Depending on the topic, these could range from concept papers to stocktaking that catalogs existing tools and guidelines, identifies gaps, and proposes or develops new or additional tools to address those gaps. Four things are clear from this exercise. First, scaling is more important than ever to solving the issues of international development, and that is now recognized by a large and growing number of people and institutions. Second, scaling has come a long way in the last twenty years in terms of our understanding of what is good practice; and the development of tools and guidelines to translate that understanding into action. The depth, breadth, and sophistication of the topics identified in this paper stand on the foundations of those accomplishments and deserve acknowledgement. Third, there is a broad, rich, and deep ongoing conversation about scaling. In regard to both the progress and current conversation, the CoP has clearly played an important role, and should continue or even expand its activities. Finally, the topics identified in this paper clearly show that there is more work to be done, and while daunting, the task is also tremendously exciting.

Despite increasing discussion within the international development community about the importance of scaling, actual scaling activities and the resources devoted to it remain at a low level. This contributes to the general underperformance of development assistance compared to the need and threatens to prevent the global community from achieving the Sustainable Development Goals (SDGs), delivering on climate change commitments, and achieving the intended results of numerous other global initiatives.

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.

A recent Working Paper for the Scaling Community of Practice (COP) identified a number of crosscutting issues whose further exploration would benefit the entire COP membership. One of these was the relationship between Scaling and Systems. There has been a vigorous debate in the scaling community on the extent to which systems need to be taken into account in scaling efforts, or even if the starting point for change efforts should be systems change rather than scaling innovations.3 Accordingly, the COP decided to organize a Webinar to explore the relationship between systems and scaling. This note serves to provide background for that Webinar, to frame the issues and identify questions for discussion. It draws on a cursory review of some of the literature on scaling and systems as well as discussions with COP members on these topics. A bibliography is provided at the end. Some consideration of systems in scaling is largely uncontroversial amongst scaling practitioners, though unfortunately this consensus is not yet reflected in many actual scaling efforts. The basic argument is that by taking systems into account, scaling efforts can align with systemic constraints and achieve a minimum objective of sustainable impact at scale. The debate arises over whether there should be greater engagement with systems in terms of breadth, depth, and explicit objectives for systems change (rather than taking systems constraints as largely given) in order to increase impact, coverage, reach and sustainability. It is important to note that the scaling and systems discussion is not being conducted in terms of welldefined and commonly agreed upon parameters or dimensions, i.e., the terms of the debate are not clear. One of the goals of this note is to try to provide some common terms to facilitate a productive conversation. However, this is complicated by the fact that participants in this conversation are coming from different disciplines, sit in different types of organizations including funders, innovators, and implementing organizations, and play different roles in scaling. Perhaps most importantly, they likely represent a range of systems “takers” vs. “makers” in terms of their capacity to take systems into account, let alone effect systems change. Indeed, one of the findings of this paper is that a more thorough attempt to frame the parameters of systems and scaling is needed.

Background: Achieving system-level, sustainable ‘scale-up’ of interventions is the epitome of successful translation of evidence-based approaches in population health. In physical activity promotion, few evidence-based interventions reach implementation at scale or become embedded within systems for sustainable health impact. This is despite the vast published literature describing efficacy studies of small-scale physical activity interventions. Research into physical activity scale-up (through case-study analysis; evaluations of scale-up processes in implementation trials; and mapping the processes, strategies, and principles for scale-up) has identified barriers and facilitators to intervention expansion. Many interventions are implemented at scale by governments but have not been evaluated or have unpublished evaluation information. Further, few public health interventions have evaluations that reveal the costs and benefits of scaled-up implementation. This lack of economic information introduces an additional element of risk for decision makers when deciding which physical activity interventions should be supported with scarce funding resources. Decision-makers face many other challenges when scaling interventions which do not relate to formal research trials of scale-up;

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.

Background
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.

About 10 years ago, a development organization and a national government took an innovative approach to a problem, the fact that people with chronic diseases were stopping their medical treatment before it was complete. After discovering that taking the medicine at the clinic was a major barrier for patients, the relatively new behavioral insights team found that allowing people to take the medicine at home (with a doctor or nurse on a camera phone) doubled the number of patients who took the entire course of medication (from 43 to 87 percent).

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.

Amplifying the impact of sustainability initiatives to foster transformations in urban and rural contexts, has received increasing attention in resilience, social innovation, and sustainability transitions research. We review the literature on amplification frameworks and propose an integrative typology of eight processes, which aim to increase the impact of such initiatives. The eight amplification processes are: stabilizing, speeding up, growing, replicating, transferring, spreading, scaling up, and scaling deep. We aggregated these processes into three categories: amplifying within, amplifying out, and amplifying beyond. This integrative typology aims to stimulate the debate on impact amplification from urban and rural sustainability initiatives across research areas to support sustainability transformations. We propose going beyond an understanding of amplification, which focuses only on the increase of numbers of sustainability initiatives, by considering how these initiatives create transformative change.

How to scale (“pathways”), whom to involve (“partnerships”), and retention of program quality (“fidelity”) are three strategic decisions that can be critical to the scale up of beneficial social programs in societies. By social program we mean an initiative intended by its developers to improve some aspect of communities. By scaling up we mean a process for significantly increasing the number of sustained implementations of a successful program, thereby serving more people with comparable benefits. Here’s an example: Gateway to College is a social program that supports communities in building sustainable pathways for disconnected youth to a high school diploma and a meaningful college credential. It was founded in 2000 at Portland Community College, in Oregon, and in 2003, the Bill & Melinda Gates Foundation provided funding to begin replication of the Gateway to College model. In 2004, Riverside Community College, in California, became the second Gateway partner college. By 2008, Gateway had expanded to 17 sites in 13 states. By 2013, 43 sites in 23 states. Did this increasing number of implementations come at a cost of lowered student success? Apparently not. Seventy-three percent of Gateway graduates continue on to post-secondary education and successfully earn college credentials. How does a program like Gateway to College scale up? To help answer this question, we collected 497 documents about 45 social programs to systematically code for strategic decisions made by lead organizations—those initiating a social program or bringing it to scale. We selected the 45 programs based on the advice of expert informants, database searching and web searches, and inclusion criteria such as program effectiveness, evidence of scale up through one of three pathways, and topical focus. We focused on the pathways they use for scaling, how they chose and then work with partner organizations, and how the program was reinvented and adapted—or not—as issues of fidelity were addressed. Because some information in which we were interested was not well represented in the available written documents, we interviewed 100 leaders and implementers associated with the 45 programs through use of a semi-structured interview protocol. Finally, we selected four programs for in-depth study through more interviews and site visits, which enriched our understanding of the work of these leadership teams and the challenges they have overcome. This purposive sampling procedure does not ensure a valid representation for extrapolating our results to all scale up activity in the given domains; rather, it is suggestive of questions and topics for further work. Ours is an exploratory study, as is much case study research.

Advancing the science of intervention scale-up is essential to increasing the impact of effective interventions at the regional and national levels. In contrast with work in high-income countries (HICs), where scale-up research has been limited, researchers in low- and middle-income countries (LMICs) have conducted numerous studies on the regional and national scale-up of interventions. In this article, we review the state of the science on intervention scale-up in both HICs and LMICs. We provide an introduction to the elements of scale-up followed by a description of the scale-up process, with an illustrative case study from our own research. We then present findings from a scoping review comparing scale-up studies in LMIC and HIC settings. We conclude with lessons learned and recommendations for improving scale-up research.

The International Fund for Agricultural Development (IFAD) has for many years stressed innovation, knowledge and scaling up as essential ingredients of its strategy to combat rural poverty in developing countries. This institutional review of IFAD’s approach to scaling up is the first of its kind: A team of development experts were funded by a small grant from IFAD to assess IFAD’s track record in scaling up successful interventions, its operational policies and processes, instruments, resources and incentives, and to provide recommendations to management for how to turn IFAD into a scaling-up institution. Beyond IFAD, this institutional scaling up review is a pilot exercise that can serve as an example for other development institutions.

About two decades ago, Jim Wolfensohn, then-President of the World Bank, visited Georgia, and noted a successful rural credit project, supported by the bank, which had improved lives for some 1,500 farmers. Upon his return, he asked the project team what they were doing to ensure the other 50,000 or so farmers in Georgia would reap similar benefits. Wolfensohn did not like the response: “Oh, it’s such a good project, someone will pick it up and run with it; we have other projects under preparation.” Not long after, he started a new initiative at the bank to develop a systematic focus on scaling up successful development interventions. A couple of years later, Wolfensohn retired from the World Bank and his successor had different priorities. This story reflects a couple of troublesome realities: first, development institutions pay too little attention to systematically scale up successful projects; and second, because of the pervasive inclination of new managers to do things differently from their predecessor, it is difficult to maintain a scaling focus in institutions.

This study reports on a review of the United Nations Development Programme’s (UNDP) country program in Tajikistan in terms of how it addresses the opportunities and challenges to scale up successful development interventions. It assesses to what extent the UNDP pursued well articulated scaling up pathways in its overall program and in specific project areas, including its communities development program, its AIDS/HIV, tuberculosis and anti-malaria program, its support for aid coordination, its disaster risk management program and its energy and environment program. The study concludes that UNDP has incorporated key elements of a scaling up approach in its Tajikistan program, but also identifies additional ways to develop a more systematic approach to scaling up. This study is part of a broader program of research and analysis carried out under the auspices of the Brookings Global Economy and Development Program.

The international community risks falling substantially short in its efforts to achieve the Sustainable Development Goals (SDGs) and the Paris Agreement climate targets by 2030. Efforts to reach the goals have focused on raising more financial resources, on tracking progress and stimulating policy reform at national and local levels, and on innovation. This article reviews these approaches and concludes that they are indeed necessary, but not sufficient, since they do not include a focus on systematically scaling successful development and climate projects and programs aimed at achieving the SDGs and climate targets. The article goes on to present a tested approach to scaling and an example of its application in four countries. A key element of the common scaling approaches, namely the identification of a clear vision of scale, i.e., a scale target, can be linked to the SDGs and climate targets, though this has not been done in the literature or in practice so far. If the SDGs and climate targets are to be attained, it will be essential that programs and projects are systematically designed and implemented to achieve scaling pathways explicitly linked with these targets. Increased financing, tracking of progress and policy reform, and innovation will be important complements to an effective scaling approach.

Womanity and the Center on Gender Equity and Health (GEH) at the University of California San Diego (UCSD) conducted a research study that sheds light on technical assistance and partnership models for adapting and scaling violence prevention programmes that better serve women and girls.

Managers who lead improve health services. Strengthening leadership and management practices and improving health management systems, when done effectively, contribute to improved health outcomes. A programmatic assessment of the impact of the leadership development program delivered by LMS Kenya offers evidence that these improvements are achievable and sustainable. Motivated managers make health systems work. Leadership development can bring new energy to address major challenges faced by health practitioners and increase overall performance and effectiveness. The LMS approach produces a critical transformation for health leaders/managers from an activity mind-set to a results mind-set. This transformation is fundamental to motivating teams, overcoming challenges and achieving better health outcomes in resource constrained settings. Multiple pathways exist from leadership and management to improved health services. LMS action-learning approaches include developing the leadership of health teams, empowering communities to create health service demand, increasing sustainability of service delivery programs and other methods. Good governance is about people and systems. LMS teams have helped developing country counterparts in public and NGO sectors to establish systems that promote transparency, social participation, and accountability. However, individuals and teams have a limited capacity to support implementation. Developing good governance, like developing leadership capacity, is a process that takes place over time, where people are challenged, offered feedback, and given support throughout the change. Start developing managers early in their careers. The largest pool of potential health care leaders and managers are the students of today in medical, nursing and public health schools. The LMS experience demonstrates that it is possible to integrate leadership and management into the pre-service curricula of academic institutions. Due to the hierarchical nature of the university system, it often takes more time to integrate these practices into a curriculum. Our experience shows, however, that once they are integrated this approach is highly sustainable. Virtual approaches address needs at scale. One way to reach many more organizations is to tap into the power of information technology. Opportunity exists to innovate and expand virtual approaches using new methods as Internet connectivity increases in the developing world, and as mobilization and support for strengthening health systems grows. Active facilitation and engagement with participants is the key. Sustainability requires practical tools that empower people to act. Approaches and tools must be designed for people to use in their own settings, and they should be practical and action-oriented. Complex, proven practices can be distilled into simple, effective and user-friendly practices that contribute to achievements in service delivery.

The term ‘scaling up’ is now widely used in the international health literature, though it lacks an agreed definition. We review what is meant by scaling up in the context of changes in international health and development over the last decade. We argue that the notion of scaling up is primarily used to describe the ambition or process of expanding the coverage of health interventions, though the term has also referred to increasing the financial, human and capital resources required to expand coverage. We discuss four pertinent issues in scaling up the coverage of health interventions: the costs of scaling up coverage; constraints to scaling up; equity and quality concerns; and key service delivery issues when scaling up. We then review recent progress in scaling up the coverage of health interventions. This includes a considerable increase in the volume of aid, accompanied by numerous new health initiatives and financing mechanisms. There have also been improvements in health outcomes and some examples of successful large-scale programmes. Finally, we reflect on the importance of obtaining a better understanding of how to deliver priority health interventions at scale, the current emphasis on health system strengthening and the challenges of sustaining scaling up in the prevailing global economic environment. Health planning, health policy, health systems

The Surgical Safety Checklist has the potential to save untold lives worldwide and to prevent even more surgical harm. Such success, however, will rest on effective implementation, which in turn will require adoption by many thousands of surgical practitioners, working in different cultures and contexts, many of them in remote, hard-to-reach areas. The World Health Organization Patient Safety Programme and the Harvard School of Public Health commissioned the United States Agency for International Development’s Health Care Improvement Project (HCI), managed by University Research Co., LLC (URC), to present its understanding of and experience with the effective adoption of simple, high-impact interventions, such as the surgical checklist. URC – through HCI and its predecessor project, the Quality Assurance Project – has over 20 years’ experience in fostering the development and spread of such innovations. URC is joined in this effort by the Institute for Healthcare Improvement (IHI), which also has decades of experience in this field. All too often in health care, evidence-based interventions that have been shown to produce superior results in certain locations do not spread to other sites. Therefore, practitioners of health care improvement have broadened their focus to not only develop superior models of care but also to take such models to larger scale by focusing on intentional spread, to more rapidly meet the needs of large numbers of patients. Such spread requires making changes in the organization of care delivery, policies, resources, and other factors that will influence the uptake of the superior model. In planning to spread an evidence-based intervention, we must consider three key questions: What are we trying to spread? To whom do we want to spread it, and by when? How will we spread it? The framework for spread requires a superior model or practice that has proven itself on a small scale through improved system results as well as a group of leaders committed to spreading this superior model. The model needs to be developed and packaged for optimal adoption by members of the social system in question. It is important to understand the social system and its constituent parts, define the full scale of the intended spread efforts, identify the leaders within the social system, and define the channels of communication. It is imperative to identify and develop champions for change. The spread plan can then be organized such that the superior model will be broadly and successfully implemented in the social system.

A key factor in closing the gap between best practice and common practice is the ability of health care providers and their organizations to rapidly spread innovations and new ideas. Pockets of excellence exist in our health care systems, but knowledge of these better ideas and practices often remains isolated and unknown to others. One clinic may develop a new way to ensure that all diabetics have their HbA1c levels checked on a regular basis, or one medical-surgical unit in a hospital may develop a consistent way to reduce pain for post-operative patients. But too often these improvements remain unknown and unused by others within the organization. Organizations face several challenges in spreading good ideas, including the characteristics of the innovation itself; the willingness or ability of those making the adoption to try the new ideas; and characteristics of the culture and infrastructure of the organization to support change. In 1999, the Institute for Healthcare Improvement (IHI) chartered a team to develop a \"Framework for Spread.\" The stated aim of the team was to \"…develop, test, and implement a system for accelerating improvement by spreading change ideas within and between organizations.\" The team conducted a review of organizational and health care literature on the diffusion of innovations, and interviewed organizations both within and outside of health care that had been successful in spreading new ideas and processes, including Luther Midelfort Health System, Mayo Health System, Virginia Mason Medical Center, and Dean Health System. Since then, the Framework for Spread and our deeper understanding of its content have continued to evolve. This white paper provides a snapshot of IHI’s latest thinking and work on spread. It is divided into two parts: The first part of the white paper describes the major spread projects that IHI has supported through early 2006, and harvests the lessons we have learned about the most effective ways to: Prepare for spread; Establish an aim for spread; and Develop, execute, and refine a spread plan. The second part of the white paper is a reprint of an article published in the June 2005 issue of the Joint Commission Journal on Quality and Patient Safety, describing how the Veterans Health Administration (VHA) used the Framework for Spread to spread improvements in access to care to more than 1,800 outpatient clinics.

There are several examples of successes in improving health care. However, many of these remain limited to the sites at which they were originally developed. There are fewer examples of successful spread of the improvement more widely inside or outside the health systems within which they were developed. This article discusses the wave-sequence approach to spread or scale up, which enables take up of the improvement in a systematic and sequential way, using “spread agents” — people who participated in the original demonstration sites. The paper also discusses the concept of the “slice” of a system which is useful for thinking about spread and considers a phenomenon related to the rate of adoption which we have observed in this wave-sequence approach.

The tools in this toolkit are those that the Scale-up Coordinators Guide focuses on. We consider this to be the basic minimum set of tools for a scale-up coordinator to guide key stakeholders on a multi-organizational team through iterative cycles of a systematic process of scale-up. That is, the phases of: 1. Engagement and assessment 2. System-oriented co-creation (planning) 3. Implementation with learning and adaptative management. For those with interest, Annex 4 of the Scale-up Coordinator’s Guide has resources with more in-depth information about the tools from which these were adapted as well as many other related tools. Tools for engagement and assessment, and for system-oriented co-creation (planning)
• 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

This paper outlines the challenge of developing an operational macroeconomic framework in Ethiopia consistent with the large envisaged scaling up of aid to achieve the Millennium Development Goals (MDGs). This paper describes an MDG scenario that addresses both microeconomic and macroeconomic constraints, such as the need to boost sustainable growth, limit Dutch disease, formulate an exit strategy from aid dependency, enhance public financial management (PFM), and expand the supply of skilled labor. The paper will argue that a carefully sequenced MDG strategy is essential so that the scaled-up aid and public spending will remain in line with Ethiopia's absorptive capacity. Keywords: Millennium Development Goals, Dutch disease, absorptive capacity, aid scaling up

This white paper aims to support those that are planning to take effective health care practices from one setting or isolated environment and to make them ubiquitous across a health care system, region, state, or nation. It is a preparation tool which is meant to guide conversation and thinking prior to the launch of a large-scale improvement effort; it considers the motivations, foundations, aims, interventions, social systems, and methods for spreading change that coordinators of such initiatives must understand and select. This white paper does not attempt to describe the rigorous process for executing a large-scale improvement initiative, which entails tight management of logistics and a great deal of focus on tactics for mobilizing involvement, measuring progress, and stimulating sustainable change within a target population. That content will be the subject for future papers and is described in some detail in publications and content on the IHI website. Since 2004, several nations have launched voluntary, large-scale initiatives to improve the quality and safety of their health care systems, with more to come.1-6 Through direct participation in—or consultation to—these initiatives in the United States, Canada, Scandinavia, the United Kingdom, and Japan, the Institute for Healthcare Improvement (IHI) has learned much about the complexities associated with such ambitious work. We have generated—and iteratively tested and refined—the following list of questions that serve as a discussion guide for those contemplating multi-stakeholder improvement initiatives that involve many caregiving organizations in a district, region, or nation. These questions fall into six sections: motivation, foundation, aim, nature of the intervention, nature of the social system, and network building (communication and support). The first three sections have emerged through first-hand learning, while the last three sections have their origins in the work of Everett Rogers and other experts on diffusion of innovation.7-12 The questions should be considered by a core group of stakeholders—those with experience in and influence over the problem in question—in the months leading up to the launch of a large-scale improvement effort. Some questions might not be relevant for some initiatives; negative or incomplete answers to any of them need not halt action. “Large-scale improvement” is a phrase that lends itself to many possible definitions. In this paper it refers to efforts that seek to stimulate change in complete, geopolitical areas through mobilization of hundreds or thousands of constituent organizations. For purposes of illustration, we offer here the example of the 100,000 Lives Campaign—an initiative the IHI led from December 2004 to June 2006 to assist hospitals across the United States in avoiding unnecessary deaths.

Innovation in health care includes important challenges: to find or create technologies and practices that are better able than the prevailing ones to reduce morbidity and mortality and to make those improvements ubiquitous quickly. In many respects in the pursuit of global health, the second challenge—the rapid spread of effective changes—seems to be the greater. Many sound (even powerful) solutions exist, such as new medicines and innovations in health care delivery, but their adoption is unreliable and slow. Often, they remain hidden in pockets around the globe, flourishing locally without reliably reaching those in need elsewhere. Some such solutions come from biomedical research, but even more take shape at the point of care, in settings where local problem solvers create effective new approaches to problems that others who live far away face as well.

The growing ability of the Humanitarian Sector to apply lightweight lean innovation techniques and deliver promising new Pilot programs has not been matched by corresponding capacity to bring these ideas to scale. The initial explanation this shortfall has been the failure of Pilots to adequately apply techniques such as User Centered Design. This focus ignores deeper more systematic challenges in the way an innovation must be transformed from a fast moving Pilot to a mature solution ready for replication. We've identified the gap between these two very different solution states as the Missing Middle of innovation. It is characterized by complex solution architecture challenges across multiple domains. In this perspective, the primary reason innovations fail to scale is not because of bad Pilots, but because of the general omission of a set of complex solution architecture tasks. Little attention has been given to this difficult work. In an effort to provide a framing model around the nature of the challenge, this paper proposes four areas that need to be intentionally addressed as part of a Scale Up initiative. The Four C's include, Completeness, Compromise, Connection and Commercials. The paper describes the nature of each of these Scale Up challenges in the light of the Humanitarian Sector.

Scaling Impact introduces a new and practical approach to scaling the positive impacts of research and innova­tion. Inspired by leading scientific and entrepreneurial innovators from across Africa, Asia, the Caribbean, Latin America, and the Middle East, this book presents a syn­thesis of unrivalled diversity and grounded ingenuity. The result is a different perspective on how to achieve impact that matters, and an important challenge to the predomi­nant more-is-better paradigm of scaling. For organizations and individuals working to change the world for the better, scaling impact is a common goal and a well-founded aim. The world is changing rapidly, and seem­ingly intractable problems like environmental degradation or accelerating inequality press us to do better for each other and our environment as a global community. Challenges like these appear to demand a significant scale of action, and here the authors argue that a more creative and critical approach to scaling is both possible and essential. To encourage uptake and co-development, the authors present actionable principles that can help organizations and innovators design, manage, and evaluate scaling strat­egies. Scaling Impact is essential reading for development and innovation practitioners and professionals, but also for researchers, students, evaluators, and policymakers with a desire to spark meaningful change.

The needs that nonprofit organizations aim to meet are immense. And they keep growing: Several factors—including demographic changes and reductions in public sector support—are on track to create a gap of $100 billion to $300 billion between the cost of meeting those needs and the level of funding that the US nonprofit sector as a whole can expect to receive in the coming years. (We developed this projection by analyzing historical rates of change in the factors that drive costs in the sector.)

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.

Background
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.

The ‘how to’ of scaling up public health interventions for maximum reach and outcomes is receiving greater attention; however, there remains a paucity of practical tools to guide those actively involved in scaling up processes in high-income countries. To fill this gap, the New South Wales Ministry of Health developed Increasing the scale of population health interventions: a guide (2014). The guide was informed by a systematic review of scaling up models and methods, and a two-round Delphi process with a sample of senior policy makers, practitioners and researchers actively involved in scaling up processes. Although it is a practical guide to assist health policy makers, health practitioners and others responsible for scaling up effective population health interventions, it can also be used by researchers in the design of research studies that are potentially suitable for scaling up, particularly where research–practice collaborations are involved. The guide is divided into four steps: step 1, ‘scalability assessment’, aims to determine if an intervention is scalable; step 2, ‘developing a scale up plan’, aims to develop a practical and workable scaling up plan that can be used to convince stakeholders there is a compelling case for action. Step 3, ‘preparing for scale up’, aims to identify ways of securing resources needed for going to scale, operating at scale, and building a foundation of legitimacy and support to sustain the scaling up effort through the implementation stage; and step 4, ‘scaling up the intervention’, involves putting the plan developed in step 2 into place. Although the guide is written as though the user is starting from the point of assessing the scalability of an intervention, later steps can be used by those already involved in scaling up to review their implementation processes. The guide is not intended to be prescriptive. Its purpose is to help policy makers, practitioners, researchers and other decision makers decide on appropriate methodological and practical choices, and balance what is desirable with what is feasible.

The Commission on Macroeconomics and Health recommended a significant expansion in funding for health interventions in poor countries. However, there are a range of constraints to expanding access to health services: as well as an absolute lack of resources, access to health interventions is hindered by problems of demand, weak service delivery systems, policies at the health and cross-sectoral levels, and constraints related to governance, corruption and geography. This special issue is devoted to analysis of the nature and intensity of these constraints, and how they can best be overcome

Landless agricultural workers and their families often go hungry between planting and harvest, the ‘lean season’ when the labour demand falls. In northern Bangladesh, my colleagues and I tested a way to ease this hunger. Instead of trying to force job creation in rural areas, we helped labourers to move temporarily to nearby cities, where construction and other jobs existed.

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.

How can brilliant but isolated experiments aimed at a solving the most pressing and complex social and ecological problems become more widely adopted and lead to transformative impact? Leaders of social change and innovation often struggle to expand their impact on social systems, and funders of such change are increasingly concerned with the scale and positive impact of their investments. In 1998, the Montreal-based J.W. McConnell Family Foundation pursued a deliberate granting strategy known as Applied Dissemination to reframe approaches to replicating successful projects. A few years later, the Foundation began convening its grantees receiving funding from the Applied Dissemination (AD) program to accelerate the impacts of their initiatives, develop a stronger understanding of the complex systems in which they worked, and to collectively begin to address some of Canada’s most intractable social problems. The AD learning group focused on peer-based learning and application, in an environment that created trust and respect among participants. The AD learning group was successful not only in improving individual and organizational efforts to accelerate and scale impact, but also in catalyzing a field of practice in Canada that focused on generating new social innovations, and scaling up and deepening the impact of those innovative initiatives. More than a decade later, the experience contains valuable lessons about effective scaling strategies, and about how to design applied learning approaches to support social innovators. Part one of this report distills important lessons from a decade of practice in accelerating impact and scaling social innovations, including the strategies used to achieve success. Part two summarizes insights from this cohort of social innovators about the design elements involved in the applied, peerbased learning process and how that ultimately built their personal and organizational capacity. This successful initiative was not without challenges though, and these are also detailed in the report.

How can brilliant but isolated experiments aimed at a solving the most pressing and complex social and ecological problems become more widely adopted and lead to transformative impact? Leaders of social change and innovation often struggle to expand their impact on social systems, and funders of such change are increasingly concerned with the scale and positive impact of their investments. In 1998, the Montreal-based J.W. McConnell Family Foundation pursued a deliberate granting strategy known as Applied Dissemination to reframe approaches to replicating successful projects. A few years later, the Foundation began convening its grantees receiving funding from the Applied Dissemination (AD) program to accelerate the impacts of their initiatives, develop a stronger understanding of the complex systems in which they worked, and to collectively begin to address some of Canada’s most intractable social problems. The AD learning group focused on peer-based learning and application, in an environment that created trust and respect among participants. The AD learning group was successful not only in improving individual and organizational efforts to accelerate and scale impact, but also in catalyzing a field of practice in Canada that focused on generating new social innovations, and scaling up and deepening the impact of those innovative initiatives. More than a decade later, the experience contains valuable lessons about effective scaling strategies, and about how to design applied learning approaches to support social innovators. Part one of this report distills important lessons from a decade of practice in accelerating impact and scaling social innovations, including the strategies used to achieve success. Part two summarizes insights from this cohort of social innovators about the design elements involved in the applied, peer-based learning process and how that ultimately built their personal and organizational capacity. This successful initiative was not without challenges though, and these are also detailed in the report.

This paper makes the case for greater use of randomized experiments "at scale." We review various critiques of experimental program evaluation in developing countries, and discuss how experimenting at scale along three specific dimensions—the size of the sampling frame, the number of units treated, and the size of the unit of randomization—can help alleviate the concerns raised. We find that program-evaluation randomized controlled trials published over the last 15 years have typically been "small" in these senses, but also identify a number of examples—including from our own work—demonstrating that experimentation at much larger scales is both feasible and valuable.

The main purpose of this paper is to provide a basis for discussing issues associated with the process of "going to scale" with programs of early childhood development. "Going to Scale" programs are described as those that attempt to reach as many potential beneficiaries as possible at a regional, national, or even worldwide level. The first section of the paper summarizes results from three analyses of successful projects and programs in an attempt to identify barriers to scale and to specify conditions, characteristics, strategies and processes accompanying successful programs. The second section examines advantages and drawbacks of three broad approaches to achieving scale, while the third section draws implications for child development programs from the preceding two sections. The final section discusses costs, organizational issues, the role of communications, evaluation, and some options for international organizations as they consider ways to increase the coverage and impact of early childhood development programs. (HOD)

Technical assistance is provided to country governments as part of international development programmes to support policymaking or strengthen state capability. This article presents the conceptual evolution of ‘technical assistance’ linked to capacity development, starting with programmes aiming exclusively to enhance individual capacity in the 1950s to 1970s and progressing to complex systems approaches in the past ten years. It also presents some of the frequent challenges in designing and implementing technical assistance, drawing from the existing literature and the authors’ experience in international development. The article summarises the latest thinking about delivering more effective development, including the adaptive management practices and the initiatives to strengthen evidence about what works. Finally, we complement this article with a follow-up open letter reflecting on the current policy options and opportunities for change.

Background:
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.

Background
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.

While the importance of pursuing integrated population, health and environment (PHE) approaches and ensuring their sustainable expansion to regional and national levels have been widely affirmed in the development field, little practical experience and evidence exist about how this can be accomplished. This paper lays out the systematic approach to scale up developed by ExpandNet and subsequently illustrates its application in the Health of People and Environment in the Lake Victoria Basin (HoPE-LVB) project, which is an integrated PHE project implemented in Uganda and Kenya from 2012–2017. Results demonstrate not only the perceived relevance of pursuing integrated development approaches by stakeholders but also the fundamental value of systematically designing and implementing the project with focused attention to scale up, as well as the challenges involved in operationalizing commitment to integration among bureaucratic agencies deeply grounded in vertical departmental approaches. Keywords: scaling up; ExpandNet; population; health and environment (PHE); institutionalization; expansion; nine step approach; development; Kenya; Uganda

Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services. Complex adaptive systems, health systems, scaling up, health planning

Few interventions that succeed in improving healthcare locally end up becoming spread and sustained more widely. This indicates that we need to think differently about spreading improvements in practice. Drawing on a focused review of academic and grey literature, the authors outline how spread, scale-up, and sustainability have been defined and operationalised, highlighting areas of ambiguity and contention. Following an overview of relevant frameworks and models, they focus on three specific approaches and unpack their theoretical assumptions and practical implications: the Dynamic Sustainability Framework, the 3S (structure, strategy, supports) infrastructure approach for scale-up, and the NASSS (non-adoption, abandonment, and challenges to scale-up, spread, and sustainability) framework. Key points are illustrated through empirical case narratives and the Element concludes with actionable learning for those engaged in improvement activities and for researchers.

The U.S. Agency for International Development (USAID) is one of the primary providers of technical assistance for health systems strengthening, and, through its global and country-level projects, it has accumulated significant experience in designing and implementing health sector reforms. One approach to health system strengthening that has been used relatively frequently by USAID-supported projects is the implementation of small-scale pilots. Such pilots enable country decision makers to “try out” a complex health system reform before deciding whether and how to roll out the reform at the national level. Pilots are often supported by evaluations that help inform the decision as to whether or not the reform should be rolled out, and may help fine-tune the reform design. While the use of pilots is not unique to health systems strengthening efforts, the piloting of health system reforms is rather different from piloting of new clinical interventions, or even service delivery modes. Complex health systems strengthening initiatives typically challenge country policymakers and implementers on multiple levels: they involve a diverse range of stakeholders, they address politically sensitive issues, they generally include multiple related components, and they frequently require skills and capacity that are in short supply in-country. Under these circumstances, piloting health system strengthening initiatives may offer particular advantages. Abt Associates, in its work for USAID on the Health Financing and Sustainability project, the Partnerships for Health Reform, and the ZdravReform project, has been involved in multiple health systems strengthening pilot programs. The contract for the Partners for Health Reformplus project (PHRplus) initially required that three pilot sites be established. The PHRplus team therefore decided that it would be important to take stock of what had been learned from previous health system strengthening pilots. Surprisingly, the published literature on this topic is minimal: papers that document pilot experiences are hard to find, and there is nothing in the literature about how to design or implement a pilot project. PHRplus conducted a review of the grey literature on piloting complex health system reforms,1 but also determined that it was important to document our own experiences of piloting. This volume represents the fruit of these efforts. It contains case studies of three health system reform pilots undertaken in Kyrgyzstan, Niger, and Rwanda during the past 15 years. Chapter 1 draws upon these experiences, as well as the broader review previously conducted, to develop a conceptual framework to assist with the design and planning of health system strengthening pilot programs, as well as summarizing the lessons learned from these three case studies and similar experiences

Background
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.

This paper contributes to the understanding of sustainability transitions by analysing processes of scaling up and out as change pathway. It defines scaling up and out as a distinct form of policy transfer focused on programme implementation, with continuity of actors across jurisdictions. We detail how scaling up and out occurs, introducing a new mechanism to policy transfer frameworks. This is explicated through the case study of Food for Life (FFL), a civil society innovation programme promoting sustainable healthy food in public settings. We highlight why FFL was scaled up and out, how this was achieved, by whom, and the results and success factors. The case study demonstrates the importance of interrogating motivations for transferring policies, and how these influence whether successful outcomes are achieved. This requires a revised framework for analysing policy transfer, with greater attention to the links between motives and outcomes, and a less binary understanding of agents\' roles. Where scaling is the mode of policy transfer, we suggest that continuous involvement of at least one transfer agent across the process is significant to success. We conclude by highlighting implications for future research into policy transfer and food system transitions.

Core development and humanitarian challenges are complex, and require processes of testing, learning and iteration to find solutions – adaptive management offers one approach for this. Yet large bureaucracies and development organisations can have low tolerance for experimentation and learning, and adaptive management can be viewed as an excuse for ‘making things up as you go along’. This briefing from the Global Learning for Adaptive Management (GLAM) initiative argues that adaptive programmes can be accountable, rigorous and high quality in how they use evidence – but this requires rethinking some key assumptions about how they are practised. The paper sets out three key elements of an ‘adaptive rigour’ approach: Strengthening the quality of monitoring, evaluation and learning data and systems. Ensuring appropriate investment in monitoring, evaluation and learning across the programme cycle. Strengthening capacities and incentives to ensure the effective use of evidence and learning as part of decision-making, leading ultimately to improved effectiveness.

Introduction: Scaling up interventions targeting non-communicable diseases (NCDs) is a global health priority, and implementation research can contribute to that effort. In 2019, the Global Alliance for Chronic Diseases funded 27 implementation research studies to improve evidence for scaling up interventions targeting prevention and/or control of hypertension and/or diabetes in low-resource settings. We examined these studies to improve the understanding of the implementation factors, including challenges and facilitators, that influence the early implementation phase of scale-up research projects targeting NCDs.

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.

Innovation is critical for delivering sustained, scalable solutions to the world\'s complex problems. From a development perspective, IDIA defines innovation is a new solution with the transformative ability to accelerate impact. Innovation can be fueled by science and technology, can entail improved ways of working with new and diverse partners, or can involve new social and business models or policy, creative financing mechanisms, or path-breaking improvements in delivering essential services and products. Innovation thrives best when facilitated by a strong ecosystem of favourable enabling conditions, including better policy and regulatory frameworks, open data and standards, and expanded access for innovators to resources. More effectively tapping into capital flows through blended finance, for instance, will harness additional resources that far exceed the current capital available for poverty reduction. The same is true when the development of science, technology and innovation (STI) capabilities is promoted, by strengthening the regulatory, infrastructure, and human capacity foundations that support the growth of local STI ecosystems. Over the next 30 years, the global community has an extraordinary opportunity to eradicate extreme poverty. That will not be easy, given a global context where: two billion more people will be added to today’s 7.3 billion; 90% of humanity will live in low and middle income countries; and crucial new disruptive influences and demands on natural resources and human capital will need to be confronted. Our world has already been dramatically transformed by the life-saving and life-improving innovations of entrepreneurs from many years ago, who saw where inadequate practices were slowing progress, and who took action to create more effective approaches. With the progress in addressing many of today’s development challenges still lagging far behind our aspirations, finding and supporting innovative solutions in a more efficient manner has become a priority for the international development community in order to enable billions of people to overcome poverty. An agenda of innovation will unleash the power of human enterprise to invent better futures. Innovations in health, agriculture, finance, and other sectors have been vital in the life-saving and life-improving breakthroughs of recent times. Where inadequate practices slow progress, more effective approaches will need to be found. The future depends on how well innovation can spur faster advances.

This report documents how the Maternal and Neonatal Health Program (1998-2004) scaled up practices and approaches at the global, regional, and country levels, providing a qualitative description of the Program\'s expanded reach, breadth, impact, and sustainability. Since 1998, the Maternal and Neonatal Health (MN/4) Program has worked to build a strategy responsive to the complexities of programming for safe motherhood. Central to the MNH Program approach is support for the use of key evidence-based maternal and neonatal care practices that build on global lessons learned about how to save the lives of mothers and newborns. The Program\'s three technical components—clinical services, behavior change interventions, and policy—provide interventions to support the appropriate use of these practices. The MNH Program\'s clinical services and policy interventions include establishing clinical standards of care, educating and training providers, and strengthening service delivery sites through performance and quality improvement. The Program\'s behavior change interventions complement the clinical services and policy components by facilitating behavioral and normative change at all levels of the healthcare system and community to increase access to, demand for, and the use of skilled life-saving care. Improving birth preparedness and complication readiness (BP/CR)— a strategy that emphasizes shared responsibility among policymakers, facilities, providers, communities, families, and women for maternal and newborn survival—provides the focus for the Program\'s work in all three technical areas. The MNH Program is currently working in 11 countries in Africa, Asia, and Latin America. Country-level program interventions are mutually supportive and are guided and supported by the Program\'s global agenda. The MNH Program contributes to the international safe motherhood effort by: z. Establishing and promoting international evidence-bawd standards for essential maternal and newborn care through global partnerships 7. Improving the quality of skilled attendance by implementing international evidence-based standards and guidelines in national policy, curricula, and competency-based training 7. Generating shared responsibility and coordinated action among policymakers, health facilities, providers, communities, families, and women through birth preparedness and complication readiness z Scaling up evidence-based safe motherhood practices, tools, and approaches by collaborating with global and national partners z. Building the evidence base for social and behavior change interventions that generate informed demand and collective action for safe motherhood

The desire to ensure that the benefits of successful small-scale social innovation are more widely available has led to a plethora of frameworks that seek to scale such innovations. We review 20 extant frameworks for scaling and distinguished four directions: up (producing changes in laws, policies, institutions or norms), down (resource allocation to support implementation), in (ensuring organizations have the capacity to deliver the type and number of good practices required) and out (geographically replicating or broadening the range or scope of good practices). In addition to these directions of scaling a generic pathway, or process, to achieve scaling is also discernible across many of the frameworks reviewed. This involves five phases: identifying, planning, implementing, learning and adapting. We stress the need for a more dynamic and systemic approach to scaling, as well as one which anticipates, addresses and assesses the extent to which scaling is inclusive of marginalized groups.

Now in its fifth edition, Diffusion of Innovations is a classic work on the spread of new ideas. In this renowned book, Everett M. Rogers, professor and chair of the Department of Communication & Journalism at the University of New Mexico, explains how new ideas spread via communication channels over time. Such innovations are initially perceived as uncertain and even risky. To overcome this uncertainty, most people seek out others like themselves who have already adopted the new idea. Thus the diffusion process consists of a few individuals who first adopt an innovation, then spread the word among their circle of acquaintances—a process which typically takes months or years. But there are exceptions: use of the Internet in the 1990s, for example, may have spread more rapidly than any other innovation in the history of humankind. Furthermore, the Internet is changing the very nature of diffusion by decreasing the importance of physical distance between people. The fifth edition addresses the spread of the Internet, and how it has transformed the way human beings communicate and adopt new ideas.

In this episode, hosts Paul Ronalds and Rachel Mason Nunn speak with Kevin Starr and Mark Reading on the innovation challenge facing NGOs, and how the NGO of the Future must be much better at taking successful innovations to scale.

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.

This guide provides information and resources to integrate adaptive learning into the design, implementation, and improvements of programs for maternal, newborn and child health services, voluntary family planning, and reproductive health care. It offers a conceptual introduction to adaptive learning, key steps to integrating into your work using links to existing resources and real-world examples of how adaptive learning can drive continuous learning and improvement in project work. MOMENTUM—or Moving Integrated, Quality Maternal, Newborn, and Child Health Services, Voluntary Family Planning, and Reproductive Health Care (MNCH/FP/RH) to Scale—is the flagship, multi-award program at the United States Agency for International Development (USAID) to accelerate reductions in maternal, newborn, and child mortality and morbidity in high-burden USAID partner countries. The purpose of this Adaptive Learning Guide is to provide MOMENTUM project teams with the information and resources to integrate adaptive learning into the design, implementation, and improvement of MNCH/FP/RH programs.

The ExpandNet Scaling Up Framework. Dissemination and advocacy. Organizing the scaling up process. Resource mobilization and cost issues. Monitoring and evaluation. WHO Tools and approaches.

Scaling of innovations is a key requirement for addressing societal challenges in sectors such as health, agriculture, and the environment. Research for development (R4D) programs, projects and other interventions struggle to make particular innovations go to scale. Current conceptualizations of scaling are often too simplistic; more systemic and multidimensional perspectives, frameworks and measures are needed. There is a gap between new complexity-aware theories and perspectives on innovation, and tools and approaches that can improve strategic and operational decision-making in R4D interventions that aim to scale innovations. This paper aims to bridge that gap by developing the key concepts and measures of Scaling Readiness. Scaling Readiness is an approach that encourages critical reflection on how ready innovations are for scaling and what appropriate actions could accelerate or enhance scaling. Scaling Readiness provides action-oriented support for (1) characterizing the innovation and innovation system; (2) diagnosing the current readiness and use of innovations as a proxy for their readiness to scale; (3) developing strategy to overcome bottlenecks for scaling; (4) facilitating and negotiating multi-stakeholder innovation and scaling processes; and (5) navigating and monitoring the implementation process to allow for adaptive management. Scaling Readiness has the potential to support evidence-based scaling strategy design, implementation and monitoring, and – if applied across multiple interventions – can be used to manage a portfolio of innovation and scaling investments.

Many countries are transforming their efforts to meet their population’s reproductive health needs by refocusing maternal and child health and family planning activities into more comprehensive reproductive health programmes. Clearly, the specific directions and magnitude of the changes involved should depend on the socio-economic context and local epidemiology of reproductive health problems, as well as on the current programmatic situation. In seeking to innovate and expand reproductive health services, programme managers and policy makers are generally advised to follow an approach that is (a) public health based - addressing key reproductive health problems, (b) pragmatic - adding interventions and services in an incremental manner and building on what already exists, and (c) participatory - recognizing what different actors can feasibly do (Fathalla, 1996). The need to identify appropriate service delivery models and subsequently scale-up successful efforts is acute. Over the past decade, the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), WHO, in collaboration with a variety of other institutions, has developed a strategic approach to contraceptive introduction that focuses on improving the quality of care in a reproductive health context. As the strategic approach was being implemented to address contraceptive introduction in several countries, its utility for addressing other specific reproductive health problems was recognized. Since then, the approach has been used for safe motherhood, abortion, reproductive tract infections/sexually transmitted infections (RTI/STIs) including human immunodeficiency virus/acquired immunodeficiency syndrome HIV/AIDS and adolescent reproductive health programmes. More recently, it has been applied as a framework for developing comprehensive reproductive health programmes. This article describes the strategic approach to contraceptive introduction and experience with its implementation. It then reviews the application of the approach to reproductive health programme development and raises some issues concerning the methodology that needs to be addressed in considering its application to reproductive health programme development.

In light of the mass disruption caused by COVID-19, we are working with our Scaling Pathways partners on a new video interview series called Scaling Through Mass Disruption, which captures how social enterprises are adapting, pivoting, managing finances, engaging teams, and so much more in times of crisis. The social enterprises interviewed share advice and insights that are not only relevant for the present situation, but also help identify trends and lessons learned that can prepare organizations for inevitable future crises and disruptions.

Discussions aim to unpack, challenge, and develop the four guiding principles of scaling science, which were identified through a comprehensive retrospective study of more than 200 research projects with real-world impact objectives. The guiding principles present an evidence-based framework for scaling impact that offers options for innovation and creativity, rather than outlining a singular pathway to success. Together they form an understanding of scaling as a coordinated effort to achieve a collection of impacts at optimal scale. This report includes discussion points regarding opportunities and challenges that researchers face in putting principles into practice.

Objective
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.

This Editorial to the Special Issue “Science of Scaling: connecting the pathways of agricultural research and development for improved food, income and nutrition security” presents the framing, overview and analysis of 10 articles focussed on scaling innovation in the agricultural research for development sector. The publications cut across three categories that focus on: (i) Understanding the scaling trajectory retrospectively from a longer term, systems perspective, (ii) Understanding scaling of innovation retrospectively as part of shorter term agricultural research for development interventions, and (iii) Conceptual or methodological approaches aimed at guiding scaling prospectively. Cross-cutting review of the publications leads to several insights and critically questions dominant ways of understanding and guiding scaling of innovation in the agricultural research for development sector. This provides a starting point for proposing more outcome-oriented scaling as a third wave of understanding and guiding scaling, beyond technology adoption (first wave) and the scaling of innovation (second wave). The Editorial proposes three Research Domains for the Science of Scaling: (1) ‘Understand the big picture of scaling innovation’ that can inform more realistic ideas about the factors, conditions and dynamics that affect innovation and scaling processes; (2) ‘Develop instruments that nurture efficient and responsible scaling’ that comprises new approaches, concepts and tools that can facilitate the development of evidence-based scaling strategies; and (3) ‘Create a conducive environment for scaling innovation’ that focusses on the institutional arrangements, partnership models, and monitoring and learning for scaling of innovation.

This chapter provides a conceptual framework for scaling up, with a focus on evidence-based reproductive health service innovations. It cites an extensive literature from several disciplines. The framework links an innovation to be scaled up with four other elements: a resource team that promotes it; a user organization expected to adopt the innovation; a strategy to transfer it; and an environment in which the transfer takes place. The authors discuss key attributes that have been found to facilitate the scaling-up process and identify strategic choices that must be made to ensure success. A final section identifies the diverse environments in which scaling up occurs, arguing that successful scale up requires tailoring strategies to the various dimensions of these settings.

This case-study explores the programmatic challenges of moving from pilot interventions to regional programmes. It documents the history of an initiative to scale up reproductive health interventions, developed and tested between 1996 and 2000 in Zambia’s Copperbelt Province. The interventions included an expansion of the range of contraceptive methods available at health facilities, the development of innovative training approaches for healthcare workers, and the testing of strategies to reach out to communities. This chapter highlights the challenges facing programme designers as they must decide which elements of a pilot study to scale up, the structures most appropriate for managing the process, and the pace and breadth of the expansion effort. Finally, it provides a conceptual framework to guide the scaling-up process and to weigh the potential trade-offs between increasing scale and the need to maintain quality, local values, local relevance and sustainability.

Scaling Pathways is a partnership between the Skoll Foundation, USAID, Mercy Corps Ventures, and CASE at Duke to curate and share scaling insights from the world’s leading social entrepreneurs.

Donors and other development partners commonly introduce innovative practices and technologies to improve health in low and middle income countries. Yet many innovations that are effective in improving health and survival are slow to be translated into policy and implemented at scale. Understanding the factors influencing scale-up is important. We conducted a qualitative study involving 150 semi-structured interviews with government, development partners, civil society organisations and externally funded implementers, professional associations and academic institutions in 2012/13 to explore scale-up of innovative interventions targeting mothers and newborns in Ethiopia, the Indian state of Uttar Pradesh and the six states of northeast Nigeria, which are settings with high burdens of maternal and neonatal mortality. Interviews were analysed using a common analytic framework developed for cross-country comparison and themes were coded using Nvivo. We found that programme implementers across the three settings require multiple steps to catalyse scale-up. Advocating for government to adopt and finance health innovations requires: designing scalable innovations; embedding scale-up in programme design and allocating time and resources; building implementer capacity to catalyse scale-up; adopting effective approaches to advocacy; presenting strong evidence to support government decision making; involving government in programme design; invoking policy champions and networks; strengthening harmonisation among external programmes; aligning innovations with health systems and priorities. Other steps include: supporting government to develop policies and programmes and strengthening health systems and staff; promoting community uptake by involving media, community leaders, mobilisation teams and role models. We conclude that scale-up has no magic bullet solution – implementers must embrace multiple activities, and require substantial support from donors and governments in doing so. Keywords Uttar Pradesh, India Northeast Nigeria Ethiopia Scale-up Maternal and newborn health Innovations

At Spring Impact, we work to strengthen the global practice around scaling social impact, through deep partnerships with organizations, and by developing and sharing insight.

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.

There are a number of routes to scaling social impact; our current focus is on replication. Replication refers broadly to taking your organisation, program or set of core principles to new locations. Our methodology is based on five stages of achieving scale through social replication. It is publicly available via our Social Replication Toolkit. The Toolkit is designed to help organisations assess their readiness for replication and to provide practical guidance through our five stages to scale. We are continuously applying this methodology across diverse sectors, geographies and cause areas. We‘ve helped shape the way leading global organisations and grassroots social ventures increase their reach, transforming the lives of those in need.

At Mulago, we obsess on the notion of social impact that goes to scale. Since we’re usually willing to pay for lunch, people often come to talk about “going to scale” and “scaling up our work.” Most of the time, the word “growth” would better capture what they have in mind. Growth is a fine thing, but scale is what solves problems, and so scale is what we look for. When we talk about “going to scale,” this is what we mean:

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?

Join the Global Community of Practice on Scaling Development Outcomes in inviting two accomplished experts, Kevin Starr and Daniel Kehrer, to share their perspectives on large-scale change from a transactional and from a systems perspective, respectively.

Scale is one of those words that means something different to just about everyone. But to measure it, to figure out concretely whether an intervention has scaled, you have to decide what you mean. So when Michael Kremer et al set out to measure the social return from innovation investments made by USAID’s Development Innovation Ventures (DIV), they selected four interventions that had “scaled” because they had reached at least a million people and used that benchmark to estimate the social return on DIV’s investment (see this excellent blog post by Jocilyn Estes, David Evans and Sarah Rose summarizing that work). As they note, the choice of a million was “an arbitrary cut-off motivated by the costliness of detailed data collection.” And on that basis, a dollar spent by DIV is judged to generate $17 worth of social impact.

Kevin Starr directs the Mulago Foundation and the Rainer Arnhold Fellows Program.

Background:
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.

Background
Complex health interventions (CHIs) are increasingly used in public health, clinical research and education to reduce the burden of disease worldwide. Numerous theories, models and frameworks (TMFs) have been developed to support implementation of CHIs.

This systematic review aims to identify and critique theoretical frameworks concerned with three features of implementation; adaptability, scalability and sustainability (ASaS). By dismantling the constituent theories, analysing their component concepts and then exploring factors that influence each theory the review team hopes to offer an enhanced understanding of considerations when implementing CHIs.

Methods
This review searched PubMed MEDLINE, CINAHL, Web of Science, and Google Scholar for research investigating the TMFs of complex health interventions. Narrative synthesis was employed to examine factors that may influence the adaptability, scalability and sustainability of complex health interventions.

Results
A total of 9763 studies were retrieved from the five databases (PubMed, MEDLINE, CINAHL, Web of Science, and Google Scholar). Following removal of duplicates and application of the eligibility criteria, 35 papers were eligible for inclusion. Influencing factors can be grouped within outer context (socio-political context; leadership funding, inter-organisational networks), inner context; (client advocacy; organisational characteristics), intervention characteristics (supervision, monitoring and evaluation), and bridging factors (individual adopter or provider characteristics).

Conclusion
This review confirms that identified TMFS do not typically include the three components of adaptability, scalability, and sustainability. Current approaches focus on high income countries or generic “whole world” approaches with few frameworks specific to low- and middle-income countries. The review offers a starting point for further exploration of adaptability, scalability and sustainability, within a low- and middle-income context.

Innovative nonprofit leaders and philanthropists have developed several effective social programs over the past decade. Despite this progress, even the most successful programs reach only a small fraction of those in need. Bridging this gap to reach transformative scale requires new strategies that extend beyond the boundaries of any single organization—new forms of collaboration within and across sectors, new platforms for learning and spreading what works, and different types of funding models. We seek to increase the number of problems being addressed at a population-level of scale.

Complex global health problems abound with devastating impact on the lives of people and the productivity of societies. Despite these challenges, public health programs have demonstrated that major successes are possible, even in the poorest of countries. For example, beginning in the 1950s Sri Lanka’s government committed to extending safe motherhood services throughout the country, including rural areas, leading to remarkable declines in maternal mortality, from an estimated 500–600 maternal deaths per 100,000 live births in the 1950s to 30 deaths per 100,000 live births in 2015. Another case in point: In 20 endemic African and Asian countries, the prevalence of Guinea worm dropped by 99%, from 3.5 million cases in 1986 to fewer than 35,000 in 2003, through behavior change efforts among multiple partners. And within a span of less than 10 years, polio was eliminated as a threat to public health in 1991 in the Americas through a region-wide effort that immunized almost every young child. Many more success cases exist. At the same time, the global health field also struggles to move effective innovations out of pilot phases into large-scale implementation to maximize their impact. On average, it takes nine years for research evidence to be implemented into practice. A recent analysis demonstrated that accelerating scale-up of a hypothetical 20-year global health program by just one year could reach 10% more people, resulting in significant impact on lives saved. Large-scale thinking is necessary to meet the global health challenges of today, yet the scale-up field is typically under-resourced and nascent. Effective and sustainable scale-up requires more than just routine implementation. It requires extra thought, attention and planning, but few programs are focused specifically on scaling up effective interventions and practices.

This paper in the IDIA Insights series focuses on eight good practices for funders seeking to take promising development innovations to scale. It is designed to accompany the Insights on Scaling Innovation paper that draws on the experience and learning of a wide range of bilateral, multilateral, philanthropic and civil society actors who came together in a Working Group on Scaling Innovation facilitated by the International Development Innovation Alliance (IDIA). While these good practices do not represent the formal strategy or approach of any one single agency in the Working Group or IDIA itself, they do reflect areas of overlapping learning and experience that can be used as a point of reference for interested stakeholders in reflecting on, and enhancing, their own approaches and guidance on scaling innovations. Scaling innovation is a long, complex and dynamic process. The good practices contained herein will therefore benefit from regular review and iteration to accurately capture continuing advances in knowledge and learning. The insights collected in this paper are also likely to be valuable in helping innovators and partner organizations develop their own scaling approaches, thereby acting as a potential catalyst for deeper and more efficient partnerships. The members of IDIA are committed to supporting the co-creation of tools and knowledge products such as these Insights papers to inform and enhance their own innovation-related work and that of others in the global innovation community. The exchange of knowledge, learning and expertise that has characterized the development of this paper is an essential part of ensuring innovations intended to help accelerate achievement of the 2030 Sustainable Development Goals can be pursued and supported.

This paper in the IDIA Insights series focuses on various challenges, lessons learned and practices of funders seeking to take promising development innovations to scale. It draws on the experience and learning of a wide range of bilateral, multilateral, philanthropic and civil society actors who came together in a Working Group on Scaling Innovation facilitated by the International Development Innovation Alliance (IDIA). While it does not represent the formal strategy or approach of any one single agency in the Working Group or IDIA itself, it does reflect areas of overlapping interest and terminology that can be used as a point of reference for interested stakeholders in reflecting on, and enhancing, their own approaches and guidance on scaling innovations. Scaling innovation is a long, complex and dynamic process. The insights contained herein will therefore benefit from regular review and iteration to accurately capture continuing advances in knowledge and practice. In its current form, this document provides a broad architecture intended to help funders as they navigate the challenging pathways associated with scaling innovation. The insights collected in this paper are also likely to be valuable in helping innovators and partner organizations develop their own scaling approaches, thereby acting as a potential catalyst for deeper and more efcient partnerships. The members of IDIA are committed to supporting the co-creation of tools and knowledge products such as these IDIA Insights papers to inform and enhance their own innovation-related work and that of others in the global innovation community. The exchange of knowledge, learning and expertise that has characterized the development of this paper is an essential part of ensuring innovations intended to help accelerate achievement of the 2030 Sustainable Development Goals can be pursued and supported.

Scaling up means to expand or replicate innovative pilot or small-scale projects to reach more people and/or broaden the effectiveness of an intervention. Based on a narrative literature review and a survey targeting key informants from 10 WHO Member States that are also members of the Regions for Health Network (RHN), this publication addresses practical challenges and provides a tool box for scaling up activities. This publication integrates and describes tools from different practical guidelines. It is structured in line with a scaling-up guideline developed for New South Wales (Australia). Using all of the presented tools in a systematic manner is often not possible for practitioners. But with references to frameworks, models and practical experiences, WHO and RHN hope to raise awareness of critical promoting or hindering actors, to encourage utilization of supportive tools, and to promote the further exchange of experiences and practical knowledge.

This piece is part of Apolitical’s spotlight series on scaling social impact, in partnership with the Bernard Van Leer Foundation. It also appears in our government innovation newsfeed. In many respects, the so-called Graduation Program has been a roaring success: it’s the only intervention proven to lift people out of extreme poverty. With food parcels, life skills classes and two years of asset transfers, it’s a complete package. Almost 100 countries have experimented with it, providing a rock-solid evidence base. So why isn’t it national policy across the world? The biggest determinant of whether an intervention will succeed at a huge scale, changing the lives of millions rather than dozens or hundreds or even thousands, is not whether it works, but whether it was designed in a way that made it suitable for scale in the first place. The path from developing a program that works to helping huge numbers of people is a long one, often taking 10 to 15 years. Organisations that don’t anticipate the difficulties will develop programs with features that make them inherently difficult or even impossible to scale up. The Graduation Program, for example, is expensive. And now governments that want to implement it are trying to cut costs — but they don’t know what to cut and what to keep without losing the effects. For reasons like this, success on a small scale is no indication, let alone a guarantee, of success on the big stage. Only interventions that are relatively simple, clearly better than the alternatives and not reliant on unique conditions are likely to scale well. But it can be done. The secret is to plan for that long journey right at the beginning and to design something that will not just survive, but thrive as it gets bigger. So how do you do that? The secret sauce The first thing to do is to understand the problem being addressed, and how the intervention solves it. "If you don’t know what that secret sauce is, you really don’t have a chance of scaling it" “Sometimes an innovation catches on, but we don’t actually know why or what is making it work,” said Whitney Pyles Adams, who runs the NGO CARE’s Scale X Design accelerator. “And if you don’t know what that secret sauce is, you really don’t have a chance of scaling it elsewhere.”

Evidence Action is an international NGO that bridges the gap between proven interventions and delivery at scale. Or rather, huge scale: they deal in the hundreds of millions. Evidence Action formally launched in 2013, and Levy has been with them from the beginning. She helped bring two of their flagship programs into operation. The first is Deworm the World. This intervention involves school-based, blanket drug administration to children in areas where worms are prevalent, with proven health and educational benefits. In 2016, almost 200 million children were treated across Africa and Asia. The second is No Lean Season. This targets seasonal poverty by offering agricultural households a travel subsidy so they can send a man to a nearby city, where he can find work and send money home. It is currently being tested in Bangladesh and Indonesia. As part of our special series on how to scale up social programs, and help millions or hundreds of millions of people rather a few thousand, we spoke to Levy about her work at Evidence Action. Your interventions are strikingly simple and scalable. How do you arrive at them? "We look for things that are elegant, well-defined and honed" When you’re expanding a program, how do you analyse prospective sites? "The world is scattered with pilot projects" Do you adapt the interventions to new contexts? Do you always design your interventions for adoption by government? "Often you need to design an intervention with government adoption in mind" Working at the scale you do, how do check whether the impact is being maintained? What’s the endgame?

Overview URC was the lead implementer for the USAID Applying Science to Strengthen and Improve Systems (ASSIST) cooperative agreement of the Office of Health Systems in USAID’s Global Health Bureau. ASSIST’s mission was to improve healthcare, strengthen health systems, and advance the frontier of improvement science in USAID-assisted countries. URC and its partners achieved these aims by: Fostering improvements in a range of healthcare processes through the application of modern improvement methods by host-country providers and managers Building the capacity of host-country systems to improve the effectiveness, efficiency, client-centeredness, safety, accessibility, and equity of the healthcare services provided Generating new knowledge to increase the effectiveness and efficiency of applying improvement methods in low- and middle-income countries Strengthening maternal, newborn, and child health (MNCH) and family planning/reproductive health services in Zika-affected countries in Latin America and the Caribbean USAID ASSIST built on the work of the USAID Health Care Improvement Project. From 2013 to 2020, ASSIST operated in over 40 countries, supporting quality improvement efforts for HIV and AIDS, MNCH, malaria, tuberculosis, Zika, orphans and vulnerable children, and non-communicable disease services at both facility and community levels.

If countries want to reach their ambitious Sustainable Development Goals targets, they need to be systematic in identifying solutions with the most potential for high impact to prioritize in their national plans. Some of these high-impact solutions, like comprehensive emergency obstetric care, will already be part of most countries’ routine care, but will be in need of improvements in quality or targeting. However, not all proven, cost-effective solutions – such as chlorhexidine for newborn sepsis prevention and integrated community case management of child illness – are currently part of routine health care practice in many countries. Scale-up is the process of bringing such newer but proven interventions and strategies to more people on a sustained basis. When governments recognize an intervention can improve the population’s health and achieve significant impact, decision-makers decide to #ScaleForSuccess. Countries can begin this process by including these newer, proven interventions in their plans, ensuring that policies are in place to support their implementation, and seeking initial financing. To make solid progress toward widespread and sustained impact, countries will also need to make a multi-year commitment to a systematic but flexible process that can successfully respond to ongoing challenges. This requires leadership, partnership, and solid management at local, district and national levels. Those leaders need timely information for a process of learning and adaptation, and strategies for ongoing resource mobilization. This is neither quick nor easy, but those who engage in such a systematic process will be rewarded with sustained and significant improvements in the health of their populations.

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 over $50 million in eight proven, transformative social enterprises to scale their impact. Program Status Update As of April 2017, the Innovation Investment Alliance has granted over $50 million to eight social enterprises operating in five different sectors. Objectives 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.

The challenges of developing, introducing, and scaling global health products—whether they are medical devices, drugs, diagnostics, vaccines, or consumer products—are innumerable. Many activities are required, across many countries, and with many actors (donors, implementing partners, ministries of health, and manufacturers, to name a few , making coordination and eƍcient execution a tricky proposition. Perhaps more signiƋcantly, developing-country public and private markets lack the resources and health infrastructure typically seen in the developed world. As a result, it often takes years, sometimes decades, for products to reach most of their intended users. In spite of such challenges, signiƋcant progress has been made. Child mortality has been cut in half over the past two decades, thanks in part to signiƋcant advancements in how global health products are developed, introduced, and scaled. Insecticide-treated nets, for example, scaled rapidly in African countries after they were made widely available in campaigns and integrated into routine health care programs. Their widespread use, along with other malaria control eƊorts, reduced malaria mortality rates in children younger than 5 years by an estimated 54 percent between 2000 and 2012 (WHO 2013). Antiretroviral treatment for HIV scaled rapidly in Africa and Asia after several global partners negotiated volume discounts and committed to deploying antiretrovirals through national health systems. By 2012, 9.7 million HIV-positive people in low- and middle-income countries were receiving treatment, an achievement that has saved an estimated 4.2 million lives and prevented 800,000 infections in children (WHO, UNICEF, and UNAIDS 2013). More recently, the Meningitis Vaccine Project orchestrated the development and introduction of a novel, low-cost group A meningococcal meningitis vaccine in Africa. The Meningitis Vaccine Project and its many partners not only developed the vaccine in record time, they deployed it quickly, reaching 100 million people within 24 months of initial regulatory approval. The vaccine has already reduced the incidence of meningitis A in the ten target countries by 95 percent. Idea to Impact: A Guide to Introduction and Scale of Global Health Innovations consolidates and shares best practices and lessons learned from decades of scaling global health innovations and draws on best practices from the private sector, while oƊering a dynamic and ƌexible home for new thinking and advancements still to come. Many of the insights and examples are heavily informed by the learnings and practices of private companies, non-governmental organizations, academia, USAID and other donors, and other public health experts.

This article proposes an initial scientific look at scaling-up, i.e., the process whereby non-governmental organizations (NGOs) increase their impact. It distinguishes four types of scaling-up—quantitative, functional, political and organizational—and discusses the paths organizations can employ to achieve these types. The article constitutes what can be called a "pre-theory:" the development of some clear definitions and taxonomies, which can constitute the basis for scientific investigation and comparative discussion. The conclusion of this article briefly presents two visions for approaching NGO scaling-up in its larger social context.

Scaling up is about “expanding impact” and not about “becoming large,” the latter being only one possible way to achieve the former. The experiences of five Indian nongovernment organizations (NGOs) suggest the emergence of a new paradigm of scaling up, in which NGOs become catalysts of policy innovations and social capital, creators of programmatic knowledge that can be spun off and integrated into government and market institutions, and builders of vibrant and diverse civil societies. We detail the mechanisms by which NGO impact can be scaled up without drastically increasing the size of the organization.

Keywords NGOs civil society Asia India advocacy scaling up

The World Hunger Program is part of the Watson Institute of International Studies at Brown University. The 1970s and 1980s have witnessed a dramatic growth in the number, the size and the level of activity of non-profit/non-governmental organizations (NGOs) in the Third World. They include peasant associations, neighborhood associations, people's movements, community initiatives, urban action committees and intermediary NGOs, filling the ranks of what is often referred to as the "associative sector." This phenomenon parallels a slow but profound change in the international aid system. Since the middle of the 1970s, donor agencies have be come increasingly preoccupied with the issue of participation and have looked to Northern and Southern NGOs as the vehicles for carrying forward an agenda of participation. As a result, both the numbers of international and local NGOs and the number of do nor funded projects that have a participation component within them have grown remarkably over the past ten years. This growth in size, number and activities of organized participatory initiatives has become recognized within the development community as" scaling-up." It constitutes an objective, or desire, of many funders, field practitioners and scholars alike. However, some important questions about scaling-up need to be answered. What role do the participants that expand the ranks of the scaled up organizations play within these organizations or within their funded projects? Is there a relationship between donor support of scaling-up and constituent participation? In what way will this new interest in scaling-up affect the rank and file of the participation movement? Has the redirection of development assistance toward scaling-up initiatives been effective? As Edwards and Hulme stated it: "how can [NGOs] increase their development impact without losing their traditional flexibility, value-base and effectiveness at the local level?"[1] Together, these questions constitute a research agenda that, to date, has not received adequate attention. Indeed, most of the literature on grassroots development movements is normative in nature; the rest is largely anecdotal. It is as if the usual laws of scientific inquiry, verification and experimentation do not apply when dealing with organizations whose social goals have often eluded the same rigors of measurement administered among the bottom lines of government and for-profit organization.[2] This article proposes a first scientific look at scaling up. It does not present any grand theory of scaling up, nor is it the result of detailed comparative field research. Rather, it represents what can be called a "pre-theory:" the development of some clear definitions and taxonomies, which can constitute the basis for scientific investigation and discussion.

This article proposes some clear definitions and taxonomies of scaling up, i.e., the processes by which grassroots organizations expand their impact. It then goes on to apply this taxonomy of scaling up to 25 Third World organizations that were nominated for the Alan Shawn Feinstein Hunger Awards, a yearly set of three awards given by Brown University to organizations that have been especially meritorious in combating or preventing hunger. This case study describes a number of paths for scaling up that might have general relevance.

Over the last two decades, two profound changes, one institutional and one conceptual, have taken place in the fight against hunger and poverty. At the institutional level, tens of thousands of new community-based organizations have come into being: they now play key roles in the many facets of the fight to eradicate hunger and poverty. At the conceptual level. the definition of food security, and of the ways to achieve it. has undergone profound changes, away from a technical, primarily food production focus, towards an approach that is at the same time much more holistic and more political, involving empowerment and freedom, health and education. agriculture and off-farm employment. These two processes are linked: new actors propose new definitions. pressure old actors, who are in turn influenced by them. Thus, we now have a much greater institutional and conceptual diversity, providing at the same time new opportunities. challenges, and difficulties in the fight against hunger and poverty. In this respect, the veritable explosion of community-based, participatory. grassroots action in most of the Third World over the last two decades seems to be a most important and encouraging trend. Throughout the world, there are literally millions of grassroots organizations (GROs) and tens of thousands of non-governmental organizations (NG0s) seeking to increase agricultural production. improve basic health care. increase poor people's incomes, design safety nets against exceptional entitlement shun-falls. improve the quality of the environment. change dietary practices. curb fertility rates, and assure access to land, water, and market opportunities. Their creativity and diversity arc unparalleled. Yet. recognizing the importance of these organizations in the fight against hunger does not imply that there is no longer a role for governments, international organizations, private enterprises, research institutions, aid agencies, and the like. All these institutions remain crucial in the fight against hunger: they have financial, legal, and intellectual resources that NGOs and GROs are unlikely ever to possess. Hence, even within a vision that stresses the capacities and creativity of local communities, it remains true that governments and international organizations are crucial actors in the fight against hunger. The issue is not their destruction, or neglect, but rather the creation of links between them and the grassroots. What is required, then, is the creation of interactions between the grass-roots and what can be called "the summit." in ways that are beneficial to local communities and poor people. This question of how to "link the grassroots to the summit" is at the cutting edge of current thinking about development strategies. Linking the grassroots to the summit implies two processes. One is scaling up, a term referring to the process by which grassroots organizations expand their impact and enter into relations with the summit.

Social and sustainable initiatives generally start small and need to scale to create substantial impact. Our systematic review of 133 articles develops a better understanding of this scaling process. From the literature, we conceptualize impact as the result of two different pathways: ‘scaling out’ (extending geographical space or volume) and ‘scaling up’ (influence on public discourses, political agendas and legislation). The review identified strategy, actor characteristics and institutional environment as key factors for scaling. The literature indicates that for strategy a focus on open structures generates speed and higher impact, but we also found critical views on this. The literature shows that the actor characteristics such as the ambition to scale, equal focus on the economic and the social logic, entrepreneurial skills and leadership are positively related to the level of impact. The institutional environment influences actor characteristics and strategy choices and also has a direct effect on the level of social and sustainable impact.

This paper provides guidance on how to do a stakeholder analysis, whether the aim is to conduct a policy analysis, predict policy development, implement a specific policy or project, or obtain an organizational advantage in one's dealings with other stakeholders. Using lessons learned from an analysis of alcohol policy development in Hungary, it outlines issues to be considered before undertaking the stakeholder analysis concerning the purpose and time dimensions of interest, the time-frame and the context in which the analysis will be conducted. It outlines advantages and disadvantages of an individual or team approach, and of the use of insiders and outsiders for the analysis. It describes how to identify and approach stakeholders and considers the use of qualitative or quantitative data collection methods for estimating stakeholder positions, levels of interest and influence around an issue. A key message is that the process of data collection and analysis needs to be iterative; the analyst needs to revise and deepen earlier levels of the analysis, as new data are obtained. Different examples of ways of analyzing, presenting and illustrating the information are provided. Stakeholder analysis is a useful tool for managing stakeholders and identifying opportunities to mobilize their support for a particular goal. However, various biases and uncertainties necessitate a cautious approach in using it and applying its results.

Background
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

Cost-effective public health interventions are not reaching developing country populations who need them. Programmes to deliver these interventions are too often patchy, low quality, inequitable, and short-lived. We review the challenges of going to scale—ie, building on known, effective interventions to achieve universal coverage. One challenge is to choose interventions consistent with the epidemiological profile of the population. A second is to plan for context-specific delivery mechanisms effective in going to scale, and to avoid uniform approaches. A third is to develop innovative delivery mechanisms that move incrementally along the vertical-to-horizontal axis as health systems gain capacity in service delivery. The availability of sufficient funds is essential, but constraints to reaching universal coverage go well beyond financial issues. Accurate estimates of resource requirements need a full understanding of the factors that limit intervention delivery. Sound decisions need to be made about the choice of delivery mechanisms, the sequence of action, and the pace at which services can be expanded. Strong health systems are required, and the time frames and funding cycles of national and international agencies are often unrealistically short.

Introduction
Realisation of proven telemedicine scale-up benefits is a key consideration for South Africa, a developing country with a quadruple disease burden, inequitable access to healthcare, and ineffective and inefficient specialist referral pathways. Proven benefits of teledermatology include virtually enhancing access of rural communities to scarce urban specialist dermatologists, reducing time to triage of skin lesions, frequently an initial sign of underlying disease, and timely treatment initiation. Benefits realisation management (BRM) is a recognised means of managing how resources are invested into making effective and desirable changes, and enhancing project and programme success. The need for this study was identified in a recent review and critique of teledermatology and related scale-up frameworks. This study explores the use of BRM as a whole life-cycle approach applied to ehealth or teledermatology related scale-up framework development, and to sustain benefits of scaling ehealth or healthcare service delivery interventions.
Material and methods
A structured search of academic literature was performed using Scopus, Science Direct, PubMed, IEEE Explore, Web of Science, and Google Scholar. The key terms Benefits Realisation Management or BRM were linked with: a) ehealth or telehealth or telemedicine or teledermatology related scale-up framework development, and b) sustainability of interventions such as scale-up. Subsequent Google searching explored grey literature evidence for BRM in ehealth.
Results
The academic literature searches could not identify peer-reviewed literature to support the use or consideration of BRM as a whole life-cycle approach within ehealth or teledermatology related scale-up framework development.
Discussion
However, the results showed that BRM has been used in related domains to promote sustainability of non-healthcare interventions. In contrast the grey literature provided evidence of limited use of BRM within healthcare and within ehealth.
Conclusions
There is renewed support for the use of BRM as a whole life-cycle approach for management disciplines that focus on change, project, programme, and portfolio management. Although limited, the academic and grey literature provides support for consideration of BRM in ehealth, and for the use of BRM to ensure sustainability. Future research should explore the use of BRM as a whole life-cycle approach for ehealth implementation, and teledermatology scale-up framework development in particular, including its possible contribution to sustaining scaled-up teledermatology.

The Global Solutions Summit (GSS 2018) convened at the United Nations Headquarters in New York City on June 4, 2018 with support from the UN Department of Economic and Social Affairs, the UN Conference on Trade and Development, the UN Commission on Science and Technology for Development, and the UN Office of Partnerships. The official theme of GSS 2018 was “From Lab to the Last Mile: Technology Deployment Business Models for the SDGs.” 1 Why is technology deployment relevant for the SDGs? At a recent speech to the UN Food and Agricultural Organization in Rome, Dr. Akinwumi Adesina, President of the African Development Bank, answered this question simply, succinctly, and eloquently when he noted, “Technologies to achieve Africa’s green revolution exist. For the most part, they are all just sitting on the shelves.”

Community-based health promotion with a focus on people with social disadvantages is essential to address persistently existing health inequities. However, achieving an impact on public health requires scaling up such approaches beyond manifold funded pilot projects. The aim of this qualitative review is to provide an overview of scaling-up frameworks in health promotion and to identify key components for scaling up community-based health promotion. First, we conducted a systematic search for scaling-up frameworks for health promotion in PubMed, CINAHL, Scopus, Web of Science, PsycInfo, and SportDiscus. Based on the included frameworks, we created an a priori framework. Second, we searched for primary research studies in the same databases that reported scaling-up processes of community-based health promotion. We coded the data using the a priori framework. From 80 articles, a total of 12 frameworks were eligible, and 5 were included for data extraction. The analysis yielded 10 a priori defined key components: “innovation characteristics”; “clarify and coordinate roles and responsibilities”; “build up skills, knowledge, and capacity”; “mobilize and sustain resources”; “initiate and maintain regular communication”; “plan, conduct, and apply assessment, monitoring, and evaluation”; “develop political commitment and advocacy”; “build and foster collaboration”; “encourage participation and ownership”; and “plan and follow strategic approaches”. We further identified 113 primary research studies; 10 were eligible. No new key components were found, but all a priori defined key components were supported by the studies. Ten key components for scaling up community-based health promotion represent the final framework. We further identified “encourage participation and ownership” as a crucial component regarding health equity.

Why do so many social innovations fail to have a broad impact? Successful social entrepreneurs and nonprofit organizations often “scale out” innovative solutions to local problems in order to affect more communities or numbers of individuals. When faced with institutional barriers, they are motivated to “scale up” their efforts to challenge the broader institutional rules that created the problem. In doing so, they must reorient their own and their organizations’ strategies, becoming institutional entrepreneurs in the process. This article proposes a contextual model of pathways for system change consisting of five different configurations of key variables and informed by qualitative interview data from selected nonprofit organizations. The authors argue that the journey from social to institutional entrepreneurship takes different configurations depending on the initial conditions of the innovative initiatives. Despite an expressed desire to engage in system change, efforts are often handicapped by the variables encountered during implementation.

Calls for evidence-based action are as old as writing itself. Exhortations to learn-by-doing recur whenever health system change is proposed. Learning by doing benefits from scaling operations down to tractable levels of management, testing changes that may or may not improve operations, and scaling up innovation based on lessons learned. However, the many small-scale projects and pilot studies that have proliferated in the health sector in recent decades often end without their large-scale utilization, in part because scaling up is a label signaling the end of research rather than a paradigm for generating continuous evidence to guide a sustained process of organizational change. This paper presents Ghana's experience with sequential “scaling down” of operations as a continuous process of evidence-driven scaling up. While the Sophoclean process of “learning by doing” is more complex than this phrase connotes, the Ghana example represents a practical demonstration of a paradigm for scaling up that retains the advantages of small scale “learning by doing” as a means of catalyzing the pace, operational integrity, and coverage of scaling-up. Commencing with policy responses to the 1978 Alma Ata Global Health Conference, improving access to primary health care has remained a pillar of health policy in Ghana ever since. Despite a full decade of investment in large scale policy action during the 1980s, evidence emerging in the early 1990s established that implementation of policies had failed.3 In 1992, the Ministry of Health convened an advisory committee to review problems and seek solutions that would define a new course for community health care programming. But policy debate ensued over the optimum configuration of community worker cadres and feasible means of financing community worker deployment costs. To resolve debate, a process of learning-by-doing was launched that has continued to the present (Fig. 1). The process that has been applied is adapted from a paradigm sponsored by World Health Organization to scaling up pilot project innovations.4 Specific attention in Ghana was directed to transferring the Bangladesh model for phased in research to its program development needs.5 However, the operational history of the Ghana model contrasts with antecedent Asian programs in important ways. We are therefore providing a synopsis of its history with the goal of extracting lessons that could inform program development elsewhere in Africa. This national program, founded in 1999 and implemented since 2000, is known as the Ghana Community-based Health Planning and Services (CHPS) Initiative

The last decade has seen some significant changes in international development and in the status of non-governmental organisations operating in the field. Not only has the number of NGOs virtually doubled; many of them have seen a considerable growth in their budgets, and have grown closer to governments and official aid agencies. NGOs are acknowledged by many to be more effective agents of development than governments or commercial interests ? even as a ?magic bullet? for development problems. Despite these positive trends, the real impact of the NGO sector is not well documented. This is partly because NGO performance-assessment and accountability methods are weak, and partly because NGOs are caught up increasingly in the world of official aid, which pushes them towards certain forms of evaluation at the expense of others. This unique book takes a hard and critical look at these issues, and describes how NGOs can, and must, improve the way they measure and account for their performance if they are to be truly effective.

Capacity development is a major pathway for research for development projects to scale innovations. However, both successful scaling and capacity development are held back by a persistent simplistic focus on ‘reaching more end-users’ and training at the individual level, respectively. This study provides examples of the other levels of capacity development: the organizational, cooperation and enabling environment levels. Drawing on four projects implemented by the International Maize and Wheat Improvement Center (CIMMYT) to scale conservation agriculture practices to smallholder farmers, we discovered that these three other levels are less understood, appreciated and reported on than individual training. Trainings are popular to report on because they are simple to plan, quantify, verify, and budget, and success in most projects is measured by the number of individuals reached and trained. There is little awareness and guidance on how to intentionally design and implement projects to address the other capacity development levels. Using a modified framework with clear examples of various types of capacity development activities, project leaders were able to identify and uncover activities that pertain to each of the four levels of capacity development. We argue that project teams must be aware, able, and empowered to invest in the development of capacities of local organizations and the system they operate in. They must be more explicit about the different levels of capacity development, what they mean in their context, and how to create synergies between them. The framework proposed in this paper can serve as a model for initiatives that aim to identify and address capacities at all four levels in order to contribute to large-scale sustainable change.

Countless development projects have piloted solutions that could make a difference if only applied at scale. The reality is that these pilot projects hardly ever reach the intended scale to contribute significantly to achieving the UN Sustainable Development Goals (SDGs). In this paper, we argue that two major problems undermine efforts to achieve scale in development projects. First, pilot projects are usually set up and managed in very controlled environments that make it very difficult to transition to the real world at scale. Second, poor conceptual and methodological clarity on what scaling is and how it can be pursued often results in a narrow focus on reaching numbers. Counting household adoption at the end of a grant project is a poor metric of whether these people can and will sustain adoption after the project closes, let alone if adoption will reach others and actually contributes to improved livelihoods. We advocate for a broader view on scaling that more accurately reflects the transformational change agenda of the SDGs: from reaching many to a process aiming to achieve sustainable systems change at scale. Sustainable systems change alters a sufficient number of key drivers (incentives, rules, etc.) such that the system that once perpetuated a “problem” now instead perpetuates a “solution.” This has implications on the way projects are designed and implemented. Rather than focusing on changing conditions within the project context, projects should serve as vehicles for societal change. This means that projects make most sense if designed as part of a multisector, long-term programmatic approach. Treating scaling as a transformation process helps deal with the necessary coevolution of organizational and institutional arrangements, along with the innovations in a technology or practice. To help address scaling, we present a number of frameworks that guide users to assess the scalability of innovations, design for scale from the onset of projects, and systematically think through key elements, ingredients, or success factors. We conclude that scaling requires different skills, approaches, and ways of collaborating than those required for successful implementation of pilot projects. It calls for development actors to have a mindset that allows them to creatively navigate multiple overlapping systems; likewise, they must develop a clear vision about which elements in the system the actors can and cannot address, and about where they need to collaborate strategically to exert influence. Although it is tempting to hope for the silver bullet solution that changes the world, we argue for an approach that takes scaling serious in its own right and recognizes the complexities involved in facilitating a transition to a new “normal.”

It is important that those embarking on a process to introduce a new WHO guideline or tool into their sexual and reproductive health-care programme consider that these materials are not simply documents that must be distributed, but rather that they contain health-care practices which must be introduced to providers through a well-planned process of adaptation and implementation. Procedures to implement guidance and change practices can seem long and overwhelming, but it is important to follow the principles and processes suggested in this document if change is to be sustained at the service delivery level. Even the simple updating of national guidelines with new recommendations may require other programmatic interventions, such as training or the development of supervisory materials, to ensure that updates are implemented. When the implementation of new guidance requires changes in the way services are delivered, a comprehensive introductory process is usually necessary. A collaborative and participatory adaptation process fosters ownership and buy-in among policy-makers, professional bodies and other national experts. Once a national version has been created or updated and then endorsed, the process to implement the new guidance at the service delivery level must be carefully planned. Providers can only implement a new practice it (a) they have been convinced of the need for it; (b) they have been trained in how to carry it out; (c) they are encouraged by supervisors to adopt it; (d) they have materials (guidelines, job aids, checklists) to support them in implementing the practice; and (e) their service delivery environment enables them to implement it. It is often tempting to disseminate guidelines without taking these issues into consideration, but experience has shown that, without due attention to the points mentioned, changes in quality of care will not be sustained.

Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up Nine steps for developing a scaling-up strategy A strategic approach to strengthening control of reproductive tract and sexually transmitted infections: use of the programme guidance tool Practical guidance for scaling up health service innovations Scaling up health service delivery: from pilot innovations to policies The WHO Strategic Approach to strengthening sexual and reproductive health policies and programmes A strategic assessment of reproductive health in the Lao People’s Democratic Republic Abortion in Viet Nam: An assessment of policy, programme and research issues An Assessment of the contraceptive method mix in Myanmar An Assessment of the need for contraceptive introduction in Zambia An Assessment of the need for contraceptive introduction in Viet Nam An Assessment of the need for contraceptive introduction in Brazil Contraceptive introduction reconsidered : a review and conceptual framework

Scaling up means to expand or replicate innovative pilot or small-scale projects to reach more people and/ or broaden the effectiveness of an intervention. Based on a narrative literature review and a survey targeting key informants from 10 WHO Member States that are also members of the Regions for Health Network (RHN), this publication addresses practical challenges and provides a tool box for scaling up activities. This publication integrates and describes tools from different practical guidelines. It is structured in line with a scaling-up guideline developed for New South Wales (Australia). Using all of the presented tools in a systematic manner is often not possible for practitioners. But with references to frameworks, models and practical experiences, WHO and RHN hope to raise awareness of critical promoting or hindering factors, to encourage utilization of supportive tools, and to promote the further exchange of experiences and practical knowledge.

Keywords DELIVERY OF HEALTH CARE DIFFUSION OF INNOVATION HEALTH PROMOTION PROGRAM DEVELOPMENT PROGRAM EVALUATION REGIONAL HEALTH PLANNING

Faced with the challenge of putting into practice the ideals of the Millennium Development Goals, the International Conference on Population and Development (ICPD), and other global summits of the last decade, decision-makers and programme managers responsible for sexual and reproductive health ask how they can: improve access to and the quality of family planning and other sexual and reproductive health services; increase skilled attendance at birth and strengthen referral systems; reduce the recourse to abortion and improve the quality of existing abortion services; provide information and services that respond to young people’s needs; and provide information and services that respond to young people’s needs; and integrate the prevention and treatment of reproductive tract infections, including HIV/AIDS, with other sexual and reproductive health services. To help answer these and other such questions, 25 countries have used the WHO-sponsored Strategic Approach to Strengthening and Reproductive Health Policies and Programmes. Public-sector health-care programmes, in collaboration with non-governmental organizations and international agencies, typically use the Strategic Approach. It involves a three-stage process for assisting countries to assess reproductive health needs and priorities, test policies and programme adaptations to address these needs, and then scale up successful interventions. The Strategic Approach unites concepts and practices from public health and the social and management sciences with the principles of the ICPD in its essential features: a staged implementation process that links assessment, pilot-testing, and scaling-up a systems framework to highlight the relevant factors for decision-making about appropriate services; a reproductive health philosophy of reproductive rights, gender equity, and empowerment; a focus on improving equitable access to and quality of care so that services are client-centred and responsive to community needs; a participatory process to consider the concerns of all relevant stakeholders; and country ownership of the process and the results.

“How much time does your leadership team spend on culture and people? Are these topics on the agenda of your management meetings?” These are questions that Maryana Iskander, CEO of Harambee Youth Employment Accelerator, encourages scaling organizations to ask themselves. She strongly believes that the work of defining culture and growing people ultimately drives every other performance metric in the organization— from strategy and partnerships to operational success and delivery. But what are the key talent-related topics and questions that management teams need to add to the agenda as they work to achieve impact at scale? Hint: they are not the same ones that the organization tackled during start-up and validation. As we spoke with social enterprise leaders, we found that their stories and advice on this talent evolution fell into three major categories:

Drawing on the perspectives and experience of some of the world’s leading social enterprises, this paper lays out key strategies and advice on how to use data to more effectively and efficiently scale impact. Our interviewees’ advice was three-fold: 1) to lay the foundation for data efforts by carefully considering equity and client voice; 2) to set the data building blocks—the how, what, and who of data—that will be critical for driving scale; and, with all that in place, 3) to pursue more advanced data approaches that align with the specific scaling strategies that you are pursuing.

The Yale Research Initiative on Innovation and Scale (Y-RISE) advances research on the effects of policy interventions when delivered at scale. While evaluation techniques for pilot-scale programs are well developed, complexities arise when we contemplate scaling up interventions to create policy change.

The rise in international aid to fund large-scale global health programs over the last decade has catalyzed interest in improving the science of scale-up. This Essay draws upon key themes in the emerging science of large-scale change in global health to propose a framework for explaining successful scale-up. Success factors for scaling up were identified from interviews with implementation experts and from the published literature. These factors include the following: choosing a simple intervention widely agreed to be valuable, strong leadership and governance, active engagement of a range of implementers and of the target community, tailoring the scale-up approach to the local situation, and incorporating research into implementation. The adoption of the Millennium Development Goals—coupled with the recent rise in international aid for health—has catalyzed interest in improving the science of scale-up [1]. Global health researchers have realized the need for “a quantitative, scientific framework to guide health-care scale-up in developing countries” [2], a need that has begun to draw the attention of donors [3]. Low- and middle-income countries (LMICs) have begun to study effective ways to deliver proven interventions at scale [4],[5]. Thus, there are promising signs that a “science of large-scale change in global health” is emerging [5]. In this Essay, I draw upon key themes in this emerging science to propose a framework for explaining successful scale-up. This framework is aimed at planners of scale-up processes to use in thinking about strategies for implementing a new program, policy, or intervention to scale. The term “scaling up” is now widely used in the public health literature, but there is no agreed definition. The term is primarily used, say Mangham and Hanson, to describe “the ambition or process of expanding the coverage of health interventions” [6], a working definition that I use in this article.

Background:
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.

Public health interventions should be designed with scale in mind, and researchers and implementers must plan for scale-up at an early stage. Yet, there is limited awareness among researchers of the critical value of considering scalability and relatively limited empirical evidence on assessing scalability, despite emerging methodological guidance. We aimed to integrate scalability considerations in the design of a study to evaluate a multi-component intervention to reduce unnecessary caesarean sections in low- and middle-income countries. First, we reviewed and synthesized existing scale up frameworks to identify relevant dimensions and available scalability assessment tools. Based on these, we defined our scalability assessment process and adapted existing tools for our study. Here, we document our experience and the methodological challenges we encountered in integrating a scalability assessment in our study protocol. These include: achieving consensus on the purpose of a scalability assessment; and identifying the optimal timing of such an assessment, moving away from the concept of a one-off assessment at the start of a project. We also encountered tensions between the need to establish the proof of principle, and the need to design an innovation that would be fit-for-scale. Particularly for complex interventions, scaling up may warrant rigorous research to determine an efficient and effective scaling-up strategy. We call for researchers to better incorporate scalability considerations in pragmatic trials through greater integration of impact and process evaluation, more stringent definition and measurement of scale-up objectives and outcome evaluation plans that allow for comparison of effects at different stages of scale-up.

Scale-up, scalability, evaluation

What is the Biofortification Priority Index (BPI)? The BPI is an analytical tool developed by Harvestplus to inform data-driven decisions for scaling up biofortification. It is also recognized as one of the notable innovations of the CGIAR global agricultural research partnership over the past 50 years. The BPI helps identify where investments in biofortification can have the biggest bang for the buck among 128 countries that the Index covers. The BPI provides rankings of country-level investment potential for 13 types of staple crops. What is new on the BPI? The BPI has been upgraded and expanded to include: - more biofortified crops: iron lentil, cowpea, and Irish potato; vitamin A banana/plantain; and zinc sorghum. They add to the previously available iron bean and pearl millet; vitamin A cassava, maize, and orange sweet potato; and zinc maize, rice, and wheat; - new releases of biofortified crop varieties available for scaling in the 128 countries, - new evidence on the nutrition impact of biofortified crops; and - more functions, including downloadable maps and data. Who uses the BPI? Interactive BPI website is a one-stop shop for anyone involved or interested in the development of biofortified varieties and scaling up biofortification. It is of particular use to: - Crop breeders, to guide research priorities for biofortification breeding; - NGOs and humanitarian organizations, to identify target locations for programs; - Private sector actors, to identify profitable investment opportunities for biofortified products (e.g., seed and food); - International financial institutions and governments, to guide decision-making on the introduction and scaling of biofortified crops.

The last decade has seen growing interest in scaling up of innovations to strengthen healthcare systems. However, the lack of appropriate methods for determining their potential for scale-up is an unfortunate global handicap. Thus, we aimed to review tools proposed for assessing the scalability of innovations in health. Methods We conducted a systematic review following the COSMIN methodology. We included any empirical research which aimed to investigate the creation, validation or interpretability of a scalability assessment tool in health. We searched Embase, MEDLINE, CINAHL, Web of Science, PsycINFO, Cochrane Library and ERIC from their inception to 20 March 2019. We also searched relevant websites, screened the reference lists of relevant reports and consulted experts in the field. Two reviewers independently selected and extracted eligible reports and assessed the methodological quality of tools. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. Results We identified 31 reports describing 21 tools. Types of tools included criteria (47.6%), scales (33.3%) and checklists (19.0%). Most tools were published from 2010 onwards (90.5%), in open-access sources (85.7%) and funded by governmental or nongovernmental organizations (76.2%). All tools were in English; four were translated into French or Spanish (19.0%). Tool creation involved single (23.8%) or multiple (19.0%) types of stakeholders, or stakeholder involvement was not reported (57.1%). No studies reported involving patients or the public, or reported the sex of tool creators. Tools were created for use in high-income countries (28.6%), low- or middle-income countries (19.0%), or both (9.5%), or for transferring innovations from low- or middle-income countries to high-income countries (4.8%). Healthcare levels included public or population health (47.6%), primary healthcare (33.3%) and home care (4.8%). Most tools provided limited information on content validity (85.7%), and none reported on other measurement properties. The methodological quality of tools was deemed inadequate (61.9%) or doubtful (38.1%). Conclusions We inventoried tools for assessing the scalability of innovations in health. Existing tools are as yet of limited utility for assessing scalability in health. More work needs to be done to establish key psychometric properties of these tools.

The MSP Guide, to which this Tool Guide is often referring, was published by Wageningen University & Research, CDI in 2015. In recent years, multi-stakeholder partnerships (MSPs) have become popular for tackling the complex challenges of sustainable development. This guide provides a practical framework for the design and facilitation of these collaborative processes that work across the boundaries of business, government, civil society and science. The guide links the underlying rationale for multi-stakeholder partnerships, with a clear four phase process model, a set of seven core principles, key ideas for facilitation and 60 participatory tools for analysis, planning and decision making. The guide has been written for those directly involved in MSPs – as a stakeholder, leader, action researcher, facilitator or funder – to provide both the conceptual foundations and practical tools that underpin successful partnerships. What’s inside draws on the direct experience of staff from the Centre of Development Innovation (CDI), at Wageningen University & Research, in supporting MSP processes in many countries around the world. The guide also compiles the ideas and materials behind CDI’s annual three week international course on facilitating MSPs.

Pathways to Scale aims to help early-stage innovators develop business models and partnership approaches that align with the development of their products, and envision potential pathways to bring products to scale. It introduces the most commonly found models for scaling up global health innovations, and features case studies that highlight and explain pathways taken by innovations that have begun to scale-up. It also offers a toolkit with exercises, structured questions, key considerations, and curated resources that innovators can use to identify the most suitable scaling model(s) to forge their path.

With support from Grantmakers for Effective Organizations (GEO), the authors set out to document and analyze the currently available literature on scaling, in order to both highlight the best set of resources available that are useful to funders actively pursuing grantmaking strategies around scaling impact, and to shine a light on what still needs to be studied and explored. This report is a compendium of the main findings of that work, and is arranged in the form of a funder-facing literature review (with materials selected based on their usefulness to funders and grantmakers interested in supporting scaling initiatives and listed in priority order), with links and abstracts, along with recommendations for future work.

The FRAMEWORK and various tools have also been applied in fields as diverse as food security, livelihoods, local government, early childhood education, judicial sector reform, and community policing. Field managers working in development implementing agencies (government or non); Staff and managers at funding agencies (governments, international donors, and private foundations) interested in scaling up their programs or integrating scaling up into the design of new programs; Academics in professional fields like public health, public policy, social welfare, international affairs, and international development; Monitoring and evaluation practitioners interested in integrating scaling up into the design and implementation of their monitoring and evaluation work or in managing the quality of the scaling up process.

The ISSaQ 4.0 tool enables health and social services innovation teams to assess the scaling potential of their innovations. It is a self-administered questionnaire.

This tool is the result of the project “Development of a tool to assess the potential for scaling up innovations in front-line community healthcare (Delphi-validated tool)”, funded by the Unité de soutien SSA Québec as part of the 2021-2022 transition projects. The project was carried out in collaboration with Université Laval’s Canada Research Chair in Shared Decision Making and Knowledge Translation, and received support from VITAM, a research center on sustainable health.

Scaling up health service delivery presents the ExpandNet framework based on extensive literature review followed by seven in-depth country case studies of scaling up in Africa; Asia and Latin America. The Implementation Mapping Tool (IMT) helps project teams use learning questions to conduct participatory reflection, adaptive management and documentation of the process of scaling up health and development interventions. 20 questions for developing a scaling-up case study can be used retrospectively or prospectively to document scaling-up experience. Our Practical Guidance tool can support preparing documentation related to these questions. The Beginning with the end in mind tool offers recommendations for designing and implementing a pilot, demonstration or implementation research project with scaling up in mind. It is also helpful to make mid-course corrections. The Nine Steps for developing a scaling-up strategy tool and associated worksheets are based on the ExpandNet framework and provide stepwise guidance to develop a scaling-up strategy. It can also support the management of the scaling-up process. The Practical Guidance tool identifies general scaling-up principles and provides examples from case studies of successful scale-up initiatives. It is helpful at the design stage, during implementation and to manage the scaling-up process.

Scaling up is a major challenge facing many donors, implementing agencies, and developing country governments. This challenge has stimulated operations research on how to do scaling up more effectively. In response to this challenge, two teams have recently developed strategic and operational frameworks for scaling up. One framework is the product of a collaborative effort by the WHO and the University of Michigan School of Public Health, the other was created by Management Systems International, an international development management consulting firm. The two frameworks were developed independently but with a great deal of collaboration and sharing of ideas over the last few years, and the results show a substantial consensus on what are the key elements and steps in scaling up. While these frameworks represent a significant advance in the field, both teams recognize that there is still much more to be learned about how to improve strategic management of scaling up. That is because in large part, as of this writing it has not been easy to learn lessons from existing field experience. In developing their respective frameworks, both teams have found that the existing case study literature on scaling up generally, and health services in developing countries in particular, is weak. There are few documented cases that have been published, and those that do exist are so-called “gray market” literature – internal documents, reports to donors or funders, or at best published on organizational websites. As many tend to be summaries or reports on projects as a whole which happen to be scaled up, rather than focusing on scaling up per se, it is often difficult to locate them with standard search methods. (This is why the WHO/Univ. of Michigan collaboration have created ExpandNet/WHO, a global network of public health professionals and scientists seeking to advance the practice and science of scaling-up successful health service innovations. A major focus of ExpandNet’s efforts is increasing the case literature and knowledge sharing around scaling up). Even those cases which do exist and focus on scaling up are usually not documented in ways which allows the reader to identify lessons learned about the process and management of scaling up itself. They tend, following the trend in scientifically-oriented academic medical and health journals, to emphasize a description of the project, model or innovation which was being tested, the results of the pilot project, and the success or failure of efforts to scale up that project. They do not talk about what the goals of scaling up were (and who determined them), how scaling up was done, and who did it. They rarely describe the political, health sector, or social environment in which scaling up occurred, the challenges and opportunities that environment presented, and how those challenges and opportunities were overcome and leveraged, respectively.

The Nine Steps for developing a scaling-up strategy tool and associated worksheets are based on the ExpandNet framework and provide stepwise guidance to develop a scaling-up strategy. It can also support the management of the scaling-up process.

Scaling of innovations is the process of expanding 2 the use of beneficial technologies or practices over geographies and across organizations to impact larger numbers of people. Reaching impact at scale is gaining importance, especially in light of the ambitions of the Sustainable Development Goals (SDGs). However, the positive outcomes of innovations in (pilot) projects are hardly ever replicated at scale, and if they do, the outcomes achieved often fade out after the project ends. A few important learnings about scaling are:
• 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

USAID’s Bureau for Food Security (BFS) and country missions have been implementing the Feed the Future (FTF) food security initiative since 2010. In many cases, small-scale innovations developed and introduced by FTF have since scaled up or are in the process of doing so. However, some innovations that could have gone to scale have not done so, have not reached their full-scale potential, or are not fully sustainable at scale. At the same time, the BFS has funded research by the Consortium of International Agronomic Research Centers (CGIAR) and innovation laboratories at major U.S. agricultural universities. This research has produced hundreds of innovations with varying potential to transform agriculture in developing countries, as well as more that are moving through the research pipeline. The Agency needs to be able to decide which innovations have the greatest potential for both successful scaling and significantly improving food security and reducing malnutrition across FTF countries and elsewhere. To this end, BFS asked the E3 Analytics and Evaluation Project, led by Management Systems International (MSI), to develop a toolkit to assess the scalability of agricultural innovations. The resulting Agricultural Scalability Assessment Toolkit (ASAT) draws on 15 years of experience by MSI and its team lead for this research, Dr. Richard Kohl, in scaling innovations and programs in the developing world, as well as on the literature on scaling and diffusion of innovation. This work includes extensive experience assisting FTF project design and strengthening scaling strategies, and five case studies the MSI team conducted of successful scaling up of agricultural innovations through commercial pathways in developing countries.

The ASAT is designed to provide a qualitative appraisal of an innovation’s scalability. While innovations do have intrinsic features that may make them more or less scalable in general, most of the factors affecting scaling potential can only be assessed relative to a specific socio-economic context and the characteristics of target adopters. The ASAT provides information on the strengths and weaknesses of the innovation relative to scalability, the most promising scaling up pathways (i.e., commercial, public, or public-private partnerships), and information on the extent to which target contexts -- locations and populations – and their market and public-sector capacity currently facilitate scaling.

Since 2003, MSI has been deeply engaged in efforts to study and advance the successful and sustainable scaling of social, economic and humanitarian outcomes. MSI serves as the secretariat for the Global Community of Practice on Scaling Development Outcomes, and MSI experts have authored many of the pioneering contributions on scaling. MSI representatives also frequently serve as scaling advisors to a wide range of foundations, official donors and social entrepreneurs. Our scaling efforts span a variety of sectors with application in education, agriculture, health, governance, youth employment and child welfare.

This guide is for those supporting a systematic process of scale-up. Although the process can be managed successfully in various ways, we wrote this guide specifically with the perspective that there is a “scale-up coordinator” or scale-up manager. The concept for this figure is based on that used by the United States Agency for International Development’s (USAID’s) Center for Innovation and Impact (CII), who calls this person an “Uptake Coordinator” or “Product Manager.” It is described in the text box. CII, in turn, adapted this idea from the successful experiences of the Chlorhexidine (CHX) Work Group and the US pharmaceutical industry which often employs product managers to facilitate the rollout of a new drug or vaccine and see it through to rapid and widespread use. We generalize the concept to include scale-up of a service or approach. In global health, we feel that having a specific person in charge of the various processes and tasks is critical, because there are needs for coordination that span across various roles and touch on multiple routine systems, multiple Ministry of Health (MOH) departments, other public sector institutions, various partner agencies, and private sector partners. Someone supporting scale-up needs the scope and authority to bridge these divides. In order to be effective, this person must juggle various types of activities including technical and management roles. In the experiences used illustratively in this guide, the scale-up coordinator was someone working in the country office of an agency giving technical support to country-led MOH scale-up efforts, but with the right terms of reference and level of authority, this person could also be someone within the government structure itself.

Nearly three years ago we wrote about the “Missing Middle” in the innovation lifecycle[i], a gap that kept successful pilot programs from reaching the goal of replication and optimization in multiple contexts. Since then, scaling humanitarian innovation has received a great deal of attention from the sector, with a number of new initiatives specifically focused on the scaling challenge. This, in turn, has created a growing need for working tools to assess the readiness of a pilot innovation to proceed into the scale-up process. The Scaling Assessment Map was developed by Ian Gray and Dan McClure to support the evaluation and planning for pilot innovation programs embarking on the Scale Up journey. This particular design for a scaling assessment is based on our prior work exploring the diverse challenges an innovation team must meet when working to create a sustainable ecosystem around their idea. The map is an evolving design that is in the process of being used and refined with innovation teams and mentors. In the spirit of collaboration, we are presenting the map with the hope that additional perspectives and experience can help refine both the tool and scaling practices as a whole.

The SAP Toolkit guides Scaling and Assessment Planning with corrective actions to strengthen or enable scaling up. While scaling up is complex and fraught with challenges, using the SAP Toolkit ensures your initiative has the best possible chances for scalability and will set you on the path to effectively scaled initiatives. The Toolkit is designed for a facilitator in a 1.5-day workshop. In some cases (if evidence-based documentation is available), certain components could be completed as a desk review.

This toolkit for researchers, policymakers and program implementers working in low- and middle-income countries (LMICs) provides resources to further implementation science, and strengthen stakeholder interactions, community participation and dissemination. It includes recognized and successful models, frameworks, strategies and approaches. Overcoming Barriers to Implementation in Global Health: A Toolkit for Engaging Diverse Stakeholders in Implementation Science Resources for Implementation Science Researchers Part 1: Implementation Science Methodologies and Frameworks Part 2: Participatory Research Models and Building Stakeholder Relationships Part 3: Dissemination Strategies in Evidence-based Policy and Practice

What is scaling science? the term ‘scaling science’ purposefully embraces two meanings: • First, it means scaling scientific research results to optimize impacts. That is, scaling the impacts of research for the public good. • Second, it refers to a systematic, principle-based science of scaling that can increase the likelihood that innovations will benefit society. All approaches to scaling should be questioned, tested, refined and used thoughtfully. Innovators working with IDRC find that scaling in research for development aims to achieve a scale of impact important to people and environment, and contribute to a broader system of development change. In other words, scaling means understanding how to position research results so that the solutions generated reach the people who can use them, and in a way they can endorse. At the same time, our work to synthesize this experience and apply it to advance scaling practice is one contribution to a science of scaling. Your efforts to test, refine, and improve these ideas are just as important. The IDRC scaling science exploration yielded unique information about what creates desirable change and meaningful impact. From this perspective

The Most Significant Change (MSC) technique is a dialogical, story-based technique. Its primary purpose is to facilitate program improvement by focusing the direction of work towards explicitly valued directions and away from less valued directions. MSC can also make a contribution to summative evaluation through both its process and its outputs. The technique involves a form of continuous values inquiry whereby designated groups of stakeholders search for significant program outcomes and then deliberate on the value of these outcomes in a systematic and transparent manner. To date, MSC has largely been used for the evaluation of international development programs, after having been initially developed for the evaluation of a social development program in Bangladesh (Davies, 1996). This article provides an introduction to MSC and discusses its potential to add to the basket of choices for evaluating programs in developed economies. We provide an Australian case study and outline some of the strengths and weaknesses of the technique. We conclude that MSC can make an important contribution to evaluation practice. Its unusual methodology and outcomes make it ideal for use in combination with other techniques and approaches.

The most significant change (MSC) technique is a form of participatory monitoring and evaluation. It is participatory because many project stakeholders are involved both in deciding the sorts of change to be recorded and in analysing the data. It is a form of monitoring because it occurs throughout the program cycle and provides information to help people manage the program. It contributes to evaluation because it provides data on impact and outcomes that can be used to help assess the performance of the program as a whole. Essentially, the process involves the collection of significant change (SC) stories emanating from the field level, and the systematic selection of the most significant of these stories by panels of designated stakeholders or staff. The designated staff and stakeholders are initially involved by ‘searching’ for project impact. Once changes have been captured, various people sit down together, read the stories aloud and have regular and often in-depth discussions about the value of these reported changes. When the technique is implemented successfully, whole teams of people begin to focus their attention on program impact.

This tool helps measure the progress of efforts to institutionalize or mainstream an initiative within a formal education system. Institutionalization is one approach to scaling impact in education, also referred to as “vertical scaling.” It is a process by which an initiative—or components of one—becomes embedded within the formal education system and is led and sustained by government actors. The ultimate goal is that the initiative becomes part of the government’s policies, plans, procedures, budgets, and daily activities; ideally, the initiative no longer stands alone or is branded separately, but effectively “disappears” into the broader system, helping to ensure its long-term sustainability. As such, this tool seeks to measure integration of an education initiative into the existing education system. It is intended as a dynamic planning tool for implementers, policymakers, and funders to identify and address areas that require additional attention in the process of vertical scaling. The tool is organized by education system building blocks, each of which is broken down into specific elements. For each element, there is a set of criteria to consider when assigning a score, and a column for providing an explanation for the score selected. The score is based on a scale of 1–4, with 1 representing “low institutionalization,” and 4 representing “full institutionalization.” It is important to keep in mind that the amount of progress required to move from a score of 3 to 4 is typically much greater than to move from 1 to 2. This tool measures the progress of institutionalization efforts related to one government agency or ministry, specifically the ministry of education (MoE). However, it is possible to use this tool for a different ministry if more appropriate, which should then be specified when detailing assumptions. The tool is designed to track progress toward national-level institutionalization, but in a decentralized system it can instead track institutionalization for the appropriate subnational education authorities. Notably, the tool is not meant to determine if an initiative should scale, or to assess the strength of an education system. The tool does not track other important aspects of scaling, such as impact and quality, and so ideally should be complemented with other scaling metrics. In particular, it is recommended that this tool should inform the creation and/or refinement of a broader scaling strategy and be used in conjunction with a resource such as the Center for Universal Education's (CUE) "Scaling Strategy Worksheet."

Scaling Readiness is an approach that can support organizations, projects, and programs in achieving their ambitions to scale innovations and achieve impact. Scaling Readiness encourages critical reflection on how ready innovations are for scaling, and what appropriate actions could accelerate or enhance scaling.

This book has brought together insights from a comprehensive review of relevant literature, as well as the experience of major scalingup initiatives in family planning and primary care services from Africa, Asia and Latin America. We hope that the value of conducting systematic analysis of the determinants of successful scaling up has been demonstrated by this effort. Most of the understanding about scaling up presented here stems from experiences with the expansion of family planning and related reproductive health services. In all of these cases, efforts were focused on improving public sector programmes. The relevance of the conceptual frameworks and the lessons that have emerged from the authors’ experiences, however, extend beyond these areas of application. As Skibiak et al. argued in discussing the Zambian experience in Chapter 4, “the greatest challenges in scaling up reside in the practical, organizational transformation of a small pilot study to a broad-based programmatic intervention”. The strategic choices that have to be made and the determinants of success apply across sectors and across different types of implementing agencies. Therefore the principles and lessons discussed here are not limited to reproductive health or to the public sector, but can also be of value when adapted to other areas of health and development. Because work on this book has benefited from several opportunities for ongoing intellectual exchange over a period of years, those who participated have been able to use the lessons learned to shape scalingup activities in the field. At the same time we wish to clarify that this is not a cookbook from which project managers can select specific, stepby-step recipes. It can, however, provide general principles and examples to be used in the development of scaling-up strategies uniquely appropriate to their context. The same type of marriage between universal principles and the need for local relevance and adaptation applies to the innovations discussed here. New ways of improving equitable access to good health services or of implementing strategies that empower women, communities or young people to demand quality of care, for example, must be backed by locally generated evidence. Concepts and case-studies, or internationally accepted best practices, can offer guidance on what general principles are relevant, but they do not provide detailed operational plans for how quality of care and service access can be enhanced in a specific country, province or district. Such planning requires context-specific diagnostic assessments, designs and testing through pilot or experimental projects.

This guide contains 12 recommendations on how to design pilot projects with scaling up in mind, as well as a checklist that provides a quick overview of the scalability of a project that is being planned, proposed, or in the process of implementation. Based on a combination of a comprehensive review of multiple literatures, field experience and a conceptual framework, the guide is intended for use by researchers, policy-planners, programme managers, technical-assistance providers, donors and others who seek to ensure that pilot or other programmatic research is designed in ways that lead to lasting and larger-scale impact.

The Implementation Mapping Tool (IMT) is a methodology to support reflection, corrective action and documentation as part of the process of scaling up – or planning for scale up – development interventions. It offers guidance for discussion and reflection, followed by planning for needed adaptations or other actions, while at the same time creating a record that explains how scaleup was implemented and results were achieved. In this methodology, members of a project team meet regularly with relevant stakeholders to discuss learning questions related to the scale-up process. They agree on emerging lessons and their implications for needed changes in the package of interventions or their implementation.These lessons and required adaptations are documented in a simple template (Appendix 1), creating a narrative record of why and how scaling up evolved over time. When testing and scaling up an innovation, it is important to apply the principles of adaptive management (3-7). At the center of adaptive management are responsive feedback loops in which project teams use a cyclical process of reflection, learning and necessary actions to ensure scale up progresses successfully (8-9). Use of the IMT facilitates this process and provides a qualitative record that illuminates how and why results were achieved or not. The nuances of these processes are often not fully remembered once projects have ended and key personnel with familiarity are no longer available. ExpandNet1 developed the IMT in collaboration with the Sukh Initiative in Pakistan and the Institute for Reproductive Health of Georgetown University for application in the area of health but it can be used for other areas of development as well. Although originally intended for projects that have reached the scale-up stage, it is relevant for any stage of the process – when initially testing an intervention, when developing a scale-up strategy, or for managing the scale-up process. The IMT shares some characteristics with other methods of assessing and documenting implementation, including the ‘Most Significant Change’ Technique, monthly learning diaries, and guided periodic reflection (10-13). Appendix 4 briefly describes these methods and how the IMT draws from them.

Calls for scaling up successfully tested health service innovations have multiplied over the past several years. Many acknowledge that pilot or experimental projects are of limited value unless they have larger policy and programme impact. Moreover, there is increasing recognition that proven innovations cannot simply be handed over with the expectation that they will automatically become part of routine programme implementation. While there has been progress, there is still little practical guidance on how to proceed with scaling up. This document can begin to fill this gap.

The purpose of this document is to outline a concise, step-by-step process for developing a scaling up strategy. The rationale behind such an undertaking is twofold. First, strategic planning for the expansion and institutionalization of successfully tested health systems innovations is essential, but often does not happen. As a result, effective new practices and products remain underutilized. It is hoped that the availability of this guide will encourage broader attention to systematic planning once pilot innovations have been successfully tested. Second, even when there is interest among programme managers and others in engaging in a systematic planning process, the experience, know-how and resources for doing so are often lacking. As a consequence planning remains ad hoc and is often limited to statements about broad goals and the extent of scaling up that is to be accomplished. Such expectations tend to be unrealistic unless they take into account the nature of the innovation, the capacity of the implementing organizations, the characteristics of the larger environment within which scaling up takes place and the resources available to support the process. Attention to scaling up requires systematic planning of how pilot-tested innovations can be implemented on a larger scale and achieve broad impact. Typically innovations are tested in pilot projects with special organizational, financial and human resources, which will not be available when innovations are being taken to scale. As a consequence, programme managers responsible for leading the process of “rolling out” the innovation to a sub-national or national level are faced with an enormous challenge: they have to implement the innovation on a large scale with few resources and in health systems that may be characterized by weak capacities and multiple, pressing priorities. Under such circumstances, success with scaling up calls for a careful balancing act between desired outcomes and practical realities and constraints. It also requires a planning process that is consistent with building national health systems’ capacities rather than imposing additional burdens on fragile public sector systems. This document provides guidance for such systematic strategy development. It should be kept in mind, however, that developing a strategy is only the beginning. Strategic thinking needs to continue throughout the process of implementation, requiring ongoing attention to the multiple factors that affect scaling up, as well as adjustments to the strategy whenever necessary. A scaling-up strategy, once developed, is not something that should be rigorously adhered to. Parts of it can quickly become obsolete as circumstances change, or because some factors were not adequately considered in the planning process. However, the initial plan can provide the foundation for the necessary adjustments that have to be made as scaling up proceeds.

If we want to achieve widespread educational effectiveness, we need to prevent every school and every teacher to “reinvent the wheel”. Locally effective education innovations already exist, the more pressing challenge is that of scaling them up to different contexts, all the while sustaining the shifts in practice, policy and structures these improvements require. There are some hurdles on the path to scaling that are inherent to the education sector: Effective learning is a highly personal issue. There are many individual and contextual factors that impact learning for schools and teachers to reckon with in adapting effective practices from elsewhere to their own setting. A change in school or district leadership, in Ministry staff or a Minister of Education, can be enough to sweep away carefully tested solutions. Sustaining and institutionalising innovations in education is difficult.

Aims and scope Implementation Science publishes research relevant to the scientific study of methods to promote the uptake of research findings into routine healthcare in clinical, organizational, or policy contexts. Applied health related research constantly produces new findings but often these are not routinely translated into healthcare practice. Implementation research is the scientific study of methods to promote the systematic uptake of proven clinical treatments, practices, organizational, and management interventions into routine practice, and hence to improve health. This also encompasses the de-implementation of interventions demonstrated to be of low or no clinical benefit and the study of influences on patient, healthcare professional, and organizational behavior in either healthcare or population settings. The lack of routine uptake of research findings is strategically important for the development of healthcare because it clearly places an invisible ceiling on the potential for research to enhance health. Further, it is scientifically important because it identifies the behavior of healthcare professionals and healthcare organizations as key sources of variance requiring improved empirical and theoretical understanding before effective uptake can be reliably achieved. Implementation science is an inherently interdisciplinary research area, and the journal is not constrained by any particular research tradition. Implementation Science publishes articles of high scientific rigor using the most appropriate methods to produce valid, generalizable answers to research questions. As well as hosting papers describing the effectiveness of implementation interventions, Implementation Science provides a unique home for rigorous and large-scale intervention development, evaluations of the process by which effects are achieved, economic evaluations of implementation, and the role of theory relevant to implementation research. The journal is also interested in publishing articles that present novel methods (particularly those that have a theoretical basis) for studying implementation processes and interventions. We are also interested in receiving articles that address methodologically robust study of the de-implementation of ineffective clinical and organizational practices. We welcome study protocols of large and innovative research, but these will only be considered if the study is received within 12 months of ethics approval and been approved for funding through external peer review via an established funding body at the national level in the respective country. We do not consider protocols for systematic reviews.

Background
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.

Fifteen to twenty years is how long it takes for the billions of dollars of university-based research to translate into evidence-based policies and programs suitable for public use. Over the past decade, an exciting science has emerged that seeks to narrow the gap between the discovery of new knowledge and its application in public health, mental health, and health care settings. Dissemination and implementation (D&I) research seeks to understand how to best apply scientific advances in the real world, by focusing on pushing the evidence-based knowledge base out into routine use. To help propel this crucial field forward, this book aims to address a number of key issues, including: how to evaluate the evidence base on effective interventions; which strategies will produce the greatest impact; how to design an appropriate study; and how to track a set of essential outcomes. D&I studies must also take into account the barriers to uptake of evidence-based interventions in the communities where people live their lives and the social service agencies, hospitals, and clinics where they receive care. The challenges of moving research to practice and policy are universal, and future progress calls for collaborative partnerships and cross-country research. The fundamental tenet of D&I research—taking what we know about improving health and putting it into practice—must be the highest priority. Keywords: university-based research, evidence-based politics, dissemination and implementation, D&I, health, policy

Implementation research (IR) is an emerging research area that helps research and public health programs achieve impact at scale. We sought to collate and share health research funders’ experiences with funding of IR activities in low- and middle-income countries (LMICs). We identified and grouped the funders’ strategies into 7 approaches that are considered important when supporting IR in LMICs. Our analysis offers broad direction and guidance to funding agencies and related partner organizations on important elements to consider when funding and implementing IR in LMICs.Ultimately, this work could help improve the impact of research investments in LMICs.

The first purpose of this review was to assess the impact of implementation on program outcomes, and the second purpose was to identify factors affecting the implementation process. Results from over quantitative 500 studies offered strong empirical support to the conclusion that the level of implementation affects the outcomes obtained in promotion and prevention programs. Findings from 81 additional reports indicate there are at least 23 contextual factors that influence implementation. The implementation process is affected by variables related to communities, providers and innovations, and aspects of the prevention delivery system (i.e., organizational functioning) and the prevention support system (i.e., training and technical assistance). The collection of implementation data is an essential feature of program evaluations, and more information is needed on which and how various factors influence implementation in different community settings.

John Townsend wrapped up the workshop noting two important topics the workshop did not have time to discuss: 1) ethics and 2) rights. After providing a brief summary of the day, he closed the session by stressing that partnership is key for scale up. The presentations and rich discussions at the meeting highlighted several areas that require further consideration and attention in order to move the field of implementation science forward. Some of these include:
▪ 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.

knowledge gap, service delivery, program efficiency and program effectiveness

Community case management (CCM) as applied to child survival is a strategy that enables trained community health workers or volunteers to assess, classify, treat and refer sick children who reside beyond the reach of fixed health facilities. The Nicaraguan Ministry of Health (MOH) and Save the Children trained and supported brigadistas (community health volunteers) in CCM to improve equitable access to treatment for pneumonia, diarrhoea and dysentery for children in remote areas. In this article, we examine the policy landscape and processes that influenced the adoption and implementation of CCM in Nicaragua. Contextual factors in the policy landscape that facilitated CCM included an international technical consensus supporting the strategy; the role of government in health care provision and commitment to reaching the poor; a history of community participation; the existence of community-based child survival strategies; the decentralization of implementation authority; internal MOH champions; and a credible catalyst organization. Challenges included scepticism about community-level cadres; resistance from health personnel; operational gaps in treatment norms and materials to support the strategy; resource constraints affecting service delivery; tensions around decentralization; and changes in administration. In order to capitalize on the opportunities and overcome the challenges that characterized the policy landscape, stakeholders pursued various efforts to support CCM including sparking interest, framing issues, monitoring and communicating results, ensuring support and cohesion among health personnel, supporting local adaptation, assuring credibility and ownership, joint problem solving, addressing sustainability and fostering learning. While delineated as separate efforts, these policy and implementation processes were dynamic and interactive in nature, balancing various tensions. Our qualitative analysis highlights the importance of supporting routine monitoring and documentation of these strategic operational policy and management issues vital for CCM success. We also demonstrate that while challenges to CCM adoption and implementation exist, they are not insurmountable. Community case management, child health, policy analysis, scaling up implementation, Nicaragua

This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts. Keywords: Diffusion of innovation, systematic review, implementation

Background
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.

Implementation science has not advanced equitable outcomes routinely, explicitly, or intentionally. Here’s how it can.

Background
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.

Background 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. family planning, Kenya, mHealth, mobile phone access

Introduction
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.

Implementation science is growing in importance among funders, researchers, and practitioners as an approach to bridging the gap between science and practice. We addressed three goals to contribute to the understanding of the complex and dynamic nature of implementation. Our first goal was to provide a conceptual overview of the process of implementation by synthesizing information from 25 implementation frameworks. The synthesis extends prior work by focusing on specific actions (i.e., the “how to”) that can be employed to foster high quality implementation. The synthesis identified 14 critical steps that were used to construct the Quality Implementation Framework (QIF). These steps comprise four QIF phases: Initial Considerations Regarding the Host Setting, Creating a Structure for Implementation, Ongoing Structure Once Implementation Begins, and Improving Future Applications. Our second goal was to summarize research support for each of the 14 QIF steps and to offer suggestions to direct future research efforts. Our third goal was to outline practical implications of our findings for improving future implementation efforts in the world of practice. The QIF's critical steps can serve as a useful blueprint for future research and practice. Applying the collective guidance synthesized by the QIF to the Interactive Systems Framework for Dissemination and Implementation (ISF) emphasizes that accountability for quality implementation does not rest with the practitioner Delivery System alone. Instead, all three ISF systems are mutually accountable for quality implementation.

Background
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.

Background
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.

Fidelity research can help to answer essential questions about the diffusion process of innovative health interventions and provide insights for further scaling-up and institutionalization. This study assessed fidelity and reinvention in the implementation of a community-based control strategy for Aedes aegypti control. The intervention was implemented in 16 study areas in La Lisa, a municipality of Havana, Cuba. Its major components were: organization & management, capacity-building, community work and surveillance. A participatory assessment of process data was performed to determine whether the components and subcomponents were implemented, not-implemented or modified. Frequencies were tabulated over all circumscriptions (lowest level of local government) and the average was calculated for the four components. Spearman Rank correlation coefficients were calculated to explore the relationships between components. In addition, semi-structured interviews were conducted with co-ordinators of the strategy at different levels to identify difficulties encountered in the strategy’s implementation. Surveillance was the most implemented component (72.9%) followed by capacity-building (54.7%). Community work and organization & management were less implemented or modified (50% and 45%, respectively). Apart from surveillance and capacity-building, all components are significantly and strongly correlated (Spearman Rank correlation coefficient > 0.70, P < 0.01). If one component is implemented in a circumscription, the other components are also likely to be implemented. It is noticeable that areas which did not undergo organizational changes commonly did not implement community work activities. Within the whole strategy, few activities were added. Scarcely implemented subcomponents were the most innovative. The difficulties encountered during implementation were related to appropriate training and skills, available time, lack of support and commitment to the strategy, lack of motivation of local leadership, and integration of actors and resources. The study showed a wide variability of fidelity in the implementation of the intervention and highlighted challenges for scaling-up and institutionalization of the community-based intervention. Cuba, dengue, community participation, fidelity research, diffusion of innovations, implementation, process evaluation

The field of implementation research is growing, but it is not well understood despite the need for better research to inform decisions about health policies, programmes, and practices. This article focuses on the context and factors affecting implementation, the key audiences for the research, implementation outcome variables that describe various aspects of how implementation occurs, and the study of implementation strategies that support the delivery of health services, programmes, and policies. We provide a framework for using the research question as the basis for selecting among the wide range of qualitative, quantitative, and mixed methods that can be applied in implementation research, along with brief descriptions of methods specifically suitable for implementation research. Expanding the use of well designed implementation research should contribute to more effective public health and clinical policies and programmes. Defining implementation research Implementation research attempts to solve a wide range of implementation problems; it has its origins in several disciplines and research traditions (supplementary table A). Although progress has been made in conceptualising implementation research over the past decade,1 considerable confusion persists about its terminology and scope.2–,4 The word “implement” comes from the Latin “implere,” meaning to fulfil or to carry into effect.5 This provides a basis for a broad definition of implementation research that can be used across research traditions and has meaning for practitioners, policy makers, and the interested public: “Implementation research is the scientific inquiry into questions concerning implementation—the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions).”

A key challenge faced by the global health community is how to take proven interventions and implement them in the real world. Affordable, life-saving interventions exist to confront many of the health challenges we face, but there is little understanding of how best to deliver those interventions across the full range of existing health systems and in the wide diversity of possible settings. Our failure to effectively implement interventions carries a price. Each year more than 287,000 women die from complications related to pregnancy and child birth, for example, while approximately 7.6 million children, including 3.1 million newborns, die from diseases that are preventable or treatable with existing interventions. Understanding implementation in the real world Implementation issues arise as a result of a range of factors including ‘real world’ contextual factors that are either overlooked or not captured by other research disciplines. Implementation research shines a light on those factors, providing the basis for the kind of context-specific and evidence-informed decision-making that is crucial to making what is possible in theory a reality in practice. Because implementation research is embedded in reality, people working in the real world (practitioners as opposed to people ‘doing research’) often ask the questions that are the starting point for new thinking. Making sure that those questions are heard, and that the research undertaken is directed at finding answers to the questions asked rather than at the topics researchers themselves may find interesting is one of the key challenges implementation researchers face. A practical tool Embedded in the real world, implementation research is also a powerful tool for capturing and analysing information in real time, allowing for the assessment of performance, for example, and facilitating health systems strengthening. Implementation research is particularly important in supporting the scale-up of interventions and their integration into health systems at the national level. Too often interventions that work in small-scale pilot studies fail to live up to expectations when rolled out in national strategies, or fail to transfer from one country to another as a result of contextual differences. Implementation research not only helps to clarify why that happens, but can be used to support the process of re-iterative refinement needed for successful adaptation. The same capacities make implementation research a useful tool for helping organizations develop the capacity to learn, enabling them to assimilate and put into effect knowledge developed on an iterative basis.

Objective:
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.

Efforts by social enterprises to develop novel interventions receive a great deal of attention. Yet these organizations often stumble when it comes to turning innovation into impact. As a result, they fail to achieve their full potential. Here’s a guide to diagnosing and preventing several “pathologies” that underlie this failure.

If the long-term benefits of public health interventions are to be realized, then ongoing program implementation or sustainability is required. Sustained implementation of public health programs, however, is a considerable challenge in complex, real-world settings. As such, understanding how to best sustain evidence-based interventions is an important area of focus within implementation science. This textbook chapter provides researchers and practitioners with the most current evidence base in sustainability research and practice, while also providing practical methods, frameworks, and tools to use when planning for, or designing, sustainability interventions and strategies. The chapter first defines sustainability and explains why it is important. The rest of the chapter presents the multi-dimensional factors that may impact sustainability and gives practitioners guidance as to how they may plan for and evaluate the sustainability of their programs. Through the use of case studies that illustrate these points, practitioners will identify how to apply sustainability frameworks, assessments, and tools in their own settings.

Implementation science seeks to address the health and development needs of populations. To have impact, these efforts must be undertaken with a focus on scale up and sustainability. This chapter discusses the definition of scale up, as well as the common characteristics of major scale-up frameworks and presents the ExpandNet/World Health Organization (WHO) systematic approach, which consists of three phases: 1. Planning and conducting implementation research and programmatic projects to increase the potential for future expansion and institutionalization of evidence-based interventions (EBIs) 2. Using knowledge about the determinants of success to guide the development of a scaling-up strategy 3. Managing the implementation of scale up These phases are discussed with emphasis on ExpandNet/WHO guidance tools and lessons learned from their application across a range of health and development interventions, providing readers with an understanding of the principles of systematic and sustainable scale up and their contribution to implementation science.

Placing partnering at the center for planning and evaluation efforts. IMPLEMENTATION, RELATIONSHIPS COLLABORATION, COMMUNITY-BASED PARTICIPATORY RESEARCH, PARTNERSHIP Practical approaches for assessing and addressing context IMPLEMENTATION CONTEXT, READINESS, SUSTAINABILITY Special issue: Hot Topics in Implementation Research and Practice WHAT OR "THE THING", 7 PS Adaptations: Culture and Context matter - why we need to consider both. IMPLEMENTATION CULTURAL ADAPTATIONS, ADAPTATION, IMPLEMENTATION SUPPORT PRACTITIONERS Considering equity and antiracism in implementation science. DESIGNING INTERVENTIONS, IMPLEMENTATION CALL TO ACTION, TCI GOALS, EQUITY AND SOCIAL JUSTICE Using human centered design for more effective implementation. DESIGNING INTERVENTIONS HUMAN-CENTERED DESIGN, DESIGNING FOR IMPLEMENTATION, STAKEHOLDER ENGAGEMENT The role of implementation facilitators. IMPLEMENTATION TRAINING, RESOURCES, FACILITATION Enhancing implementation training. TRAINING, IMPLEMENTATION CAPACITY BUILDING, TRAINING, IMPLEMENTATION SUPPORTS, IMPLEMENTATION SUPPORT PRACTITIONERS Integrating implementation science and quality improvement in training programs. TRAINING KNOWLEDGE TO ACTION, KTA, CAPACITY BUILDING, TRAINING, IMPLEMENTATION SUPPORT PRACTITIONERS Complex systems. IMPLEMENTATION COMPLEX SYSTEMS, CONTEXT, SYSTEMS THINKING

Operations research (OR) is critical in providing scientific evidence for health and disease control programs to improve their quality and “learning” as they scale up. In the context of aligning international health support, the need to develop a framework endorsed and recognized by a wider professional community as a commonly-used instrument for designing, planning, implementing and taking full advantage of effective OR has been well recognized. The Framework for Operations and Implementation Research in Health and Disease Control Programs is a result of a collaborative effort between the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Special Program for Research and Training in Tropical Diseases (TDR) and an inter-agency technical working group. The culmination of this collaboration was a three-day meeting held in Geneva in April 2008 and attended by over fifty participants representing the Global Fund, TDR, the World Health Organization (WHO), the Joint United Nations Program on HIV/AIDS (UNAIDS), United States Agency for International Development (USAID), the World Bank, field-based programs, policy-makers and research communities from all over the world, which finalized and endorsed the framework. The overall goal of the document is two-fold: to standardize the practice of OR across the international health community and to stimulate the integration of OR into health programs. In general, OR needs to be integrated as an essential part of monitoring and evaluation (M&E) efforts. Thus, the concept of M’OR’E could become a new paradigm enhancing the practice of integrating monitoring, research and evaluation dimensions as one common component into program management systems. It would not only strengthen program implementation, but would also facilitate more effective utilization of M&E resources (currently recommended at five to ten percent of overall Global Fund grant budgets). The range of target audiences for this document is wide and varies from policy-makers to program managers, from researchers to program implementers, from donors to government agencies, from technical organizations to civil society and other stakeholders. The document is divided into three main sections. Section A contains an overview of OR definitions, scope and uses. Section B is the OR process flowchart and offers a step-by-step 16-item checklist of major activities required in the planning, implementation and follow-through (dissemination and use) of OR at the country level. Section C provides case studies of OR activities from the field and an annotated reference list of available handbooks, guidelines and other tools for OR. Feedback from people who use this document will help make improvements in future editions. We strongly suggest that programs and partners use this tool to incorporate OR in a systematic way, so that we can maximize the “learning” and quality of the scale-up of health services.

In December 2018, the National Institutes of Health (NIH) and AcademyHealth co-hosted the 11th Annual Conference on the Science of Dissemination and Implementation (D&I) in Health, “Scaling up Effective Health and Healthcare: Advancing the Research Agenda and Necessary Infrastructure.” Reflecting increased interest in the field and growth in our research community, we had record attendance with nearly 1,300 researchers, practitioners and policymakers convening in Washington, DC, including a large number of attendees who had not previously taken part in the conference series. This eleventh iteration of the conference balanced its three-day research agenda among concurrent paper sessions, hundreds of posters, a keynote speaker and three plenary panels, all touching upon the conference theme of scaling up effective health and healthcare as well as building capacity and the necessary infrastructure in the field. This supplement contains the abstracts from the concurrent sessions, reflecting the variety of dissemination and implementation research supported and disseminated by our conference sponsors, including the National Institutes of Health (NIH), AcademyHealth, the Agency for Healthcare Research and Quality (AHRQ), the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation (RWJF), and the US Department of Veterans Affairs (VA). Although not included in this supplement, an additional 405 papers were presented in poster format and can be viewed at https://academyhealth.confex.com/academyhealth/2018di/meetingapp.cgi/ModulePosterSessions/0.

The current dominant models of intervention design in the development sector do not account for the complexity and unpredictability of implementation challenges. Decision makers and implementers need timely feedback during implementation to respond to field realities and to course-correct. This letter calls for a new approach of “responsive feedback” or “feedback loops” that promotes interactions between project designers, implementers, researchers and decision-makers to enable course corrections needed to achieve intended outcomes. A responsive feedback approach, in theory, should be agile, flexible, adaptive, iterative, and actionable. There can be multiple challenges associated with incorporating this approach into practice including donor requirements, organizational structure and culture, concerns about the additional time required to adopt such an approach, resource and operational constraints, the absence of skill sets needed for such an approach within smaller organizations and inadequate inter-departmental communication. However, these barriers to adaptation can be overcome. For responsive feedback to become a part of the culture of development organizations, commitment is needed from donors, decision-makers, project designers and implementers. We believe that, to generate opportunities for learning and adaptation, donors should provide the stimulus to break down silos between implementers and researchers. Keywords: Implementation science, responsive feedback, feedback loops, adaptive implementation, theory of change, monitoring and evaluation

Practical Implementation Science is designed for graduate health professional and advanced undergraduate students who want to master the steps of using implementation science to improve public health. Engaging and accessible, this textbook demonstrates how to implement evidence-based practices effectively through use of relevant theories, frameworks, models, tools, and research findings. Additional real-world case studies across public health, global health, and health policy provide essential context to the major issues facing implementation domestically and globally with consideration of communities in low-to-middle-income countries (LMIC). The textbook is organized around the steps involved in planning, executing, and evaluating implementation efforts to improve health outcomes in communities. Coverage spans assessing the knowledge-practice gap; selecting an evidence-based practice (EBP) to reduce the gap; assessing EBP fit and adapting the EBP; assessing barriers and facilitators of implementation; engaging stakeholders; creating an implementation structure; implementing the EBP; and evaluating the EBP effort. Each chapter includes a "how to" approach to conducting the task at hand. The text also addresses the practical importance of implementation science through disseminating EBPs; scaling up EBPs; sustaining EBPs; and de-implementing practices that are no longer effective. All chapters include learning objectives and summaries with emphasized Key Points for Practice, Common Pitfalls in Practice, and discussion questions to direct learning and classroom discussion. Fit for students of public health, health policy, nursing, medicine, mental health, behavioral health, allied health, and social work, Practical Implementation Science seeks to bridge the gap from scientific evidence to effective practice.

STATUS OF THE INITIATIVE
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.

Policy-makers worldwide are increasingly interested in scaling up evidence-based interventions (EBIs) to larger populations, and implementation scientists are developing frameworks and methodologies for achieving this. But scaling-up does not always produce the desired results. Why not? We aimed to enhance awareness of the various pitfalls to be anticipated when planning scale-up. In lower- and middle-income countries (LMICs), the scale-up of health programs to prevent or respond to outbreaks of communicable diseases has been occurring for many decades. In high-income countries, there is new interest in the scaling up of interventions that address communicable and non-communicable diseases alike. We scanned the literature worldwide on problems encountered when implementing scale-up plans revealed a number of potential pitfalls that we discuss in this paper. We identified and discussed the following six major pitfalls of scaling-up EBIs: 1) the cost-effectiveness estimation pitfall, i.e. accurate cost-effectiveness estimates about real-world implementation are almost impossible, making predictions of economies of scale unreliable; 2) the health inequities pitfall, i.e. some people will necessarily be left out and therefore not benefit from the scaled-up EBIs; 3) the scaled-up harm pitfall, i.e. the harms as well as the benefits may be amplified by the scaling-up; 4) the ethical pitfall, i.e. informed consent may be a challenge on a grander scale; 5) the top-down pitfall, i.e. the needs, preferences and culture of end-users may be forgotten when scale-up is directed from above; and 6) the contextual pitfall, i.e. it may not be possible to adapt the EBIs to every context. If its pitfalls are addressed head on, scaling-up may be a powerful process for translating research data into practical improvements in healthcare in both LMICs and high-income countries, ensuring that more people benefit from EBIs. Keywords: Scaling-up; cost-effectiveness; equity; ethics; evidence-based intervention; harms; health.

The following blog post is the twelth in our journey through the special edition of RE-AIM in the Frontiers in Public Health special issue! The article titled “RE-AIM in the Real World: Use of the RE-AIM Framework for Program Planning and Evaluation in Clinical and Community Settings” written by Kwan et al. (2019), shows the use of RE-AIM in the use of RE-AIM n both clinical and community-based projects in regards to understanding intervention planning, evaluation, and outcomes. This is a unique publication that shows the use of RE-AIM in a variety of samples (snowball sampling) to look at the use of dimensions and understanding of RE-AIM through a 5-point scale. To read more about this work, please click the image below to read the full text!

This report is the summary of a two-day meeting of researchers and policy makers that focussed on the process of getting research on reproductive health issues into practice. This was achieved by examining the dynamics of knowledge transfer and by identifying key actors that are involved and their roles in the dissemination and utilisation of research results. The actors who may be involved are numerous and varied, and depend on whether the results are of use in policy development or in service delivery or both. The most direct process of getting research findings into policy development could involve researchers liasing directly with macro level decision makers for example directors of public health or the heads of private, NGO or religious based health service programmes. Alternatively this liaison may be necessary at the micro level for example with district level health officers if the intention is more likely to influence programme implementation. In many instances it is possible that the expertise of communicating with decision makers is not available within research organisations and therefore researchers may need to use others, for example journalists or specialist communications organisations to communicate research results to decision makers in an effective and appropriate way. How research results are communicated to these carefully identified actors is another key area. The traditional outputs of research projects, such as final reports and peerreviewed papers, are often inaccessible to the key decision makers, either due to constraints in accessing them or the language in which they are written. However, over-condensing and the simplification of the results in an effort to improve the effectiveness of their communication, often denies the decision maker sufficient information with which to design coherent policies and practical programmes. The priority of academic researchers to publish in peer-reviewed journals for career advancement has advantages and disadvantages in terms of communicating with decision makers. Micro level decision makers often complain about lack of access to such journals, and about the lack of practical guidance in how to operationalise the findings in a service delivery programme. An advantage of communicating through journals is that being peer reviewed enables decision makers to access quality research whose methodological merits have been thoroughly scrutinised. Evaluation of the utilisation of policy- and programme-orientated research is also important. The utilisation of research by decision makers at policy and programme level is particularly important to donors, who are increasingly required to justify the funding of research programmes to their paymasters, in terms of the impact of the research on health services, and ultimately the impact on general health status. Evaluating research quality and its impact on decision-making is not straightforward and varies according to the type of research undertaken and its objectives.

The Population Council’s Frontiers in Reproductive Health program (FRONTIERS) provides technical and financial support to research that is intended explicitly to be utilized for strengthening the delivery of sexual and reproductive health services. As such, this research programme sponsors research studies for which one of the main criteria of success is whether or not the results have been used. This paper describes the findings from an assessment of eight case-studies of operations research projects undertaken during the 1990s in four countries of sub-Saharan Africa (1). The case-studies sought to identify the determinants that most commonly influenced whether and how the research results were utilized. Utilization was measured in terms of changes in health-care delivery procedures or policies by service organizations, and the extent to which the results were used by additional organizations external to the research. The assessment identified eight factors that influenced the extent to which research findings were used in all of the eight case-studies. These eight factors are described below. For each factor, the questions used to determine the extent to which utilization occurred are given, followed by a brief description of why and how each factor was influential. DEFINITION OF THE PROBLEM The more the programme managers were in a position to determine the research question the more likely they were to use the results. Utilization was greatest if they were, in effect, commissioning the research by determining the nature of the problem, specifying the research question, and determining how they would use the results, rather than simply approving a research project presented to them with limited or no consultation. In defining the problem, the programme managers considered the following questions.

Despite the considerable amount of money spent on clinical research relatively little attention has been paid to ensuring that the findings of research are implemented in routine clinical practice.1 There are many different types of intervention that can be used to promote behavioural change among healthcare professionals and the implementation of research findings. Disentangling the effects of intervention from the influence of contextual factors is difficult when interpreting the results of individual trials of behavioural change.2 Nevertheless, systematic reviews of rigorous studies provide the best evidence of the effectiveness of different strategies for promoting behavioural change. 3 4 In this paper we examine systematic reviews of different strategies for the dissemination and implementation of research findings to identify evidence of the effectiveness of different strategies and to assess the quality of the systematic reviews. Summary points Systematic reviews of rigorous studies provide the best evidence on the effectiveness of different strategies to promote the implementation of research findings Passive dissemination of information is generally ineffective It seems necessary to use specific strategies to encourage implementation of research based recommendations and to ensure changes in practice Further research on the relative effectiveness and efficiency of different strategies is required

An important goal of human development research is to generate evidence to guide improvements in policies and practices. Increasingly pressed to use proven approaches and to terminate strategies that do not work, development agencies look to research to better understand problems, to inform decision making and to identify effective solutions. Despite the critical role of research, a large gap often exists between the evidence and its widespread use in development programs.1 This “research-to-practice gap” is augmented by several factors, including limited stakeholder involvement in research, pilot project designs with little consideration for scale-up, feeble attempts to disseminate research findings and advocate their use, and the absence of tools and systematic efforts to replicate and expand evidence-based interventions. These barriers may be particularly evident in resource-constrained settings, where weak health systems further challenge the incorporation of research into practice. Designed for both researchers and program designers, this primer introduces a set of eight strategies that address these challenges and help close the gap between research and practice. The strategies are based on a growing body of evidence, theoretical frameworks, case studies and published guidance. The strategies explain how to plan, implement and disseminate research to facilitate its translation into practice. They also describe the most effective ways to incorporate research results into policies and programs. Although not exhaustive, each strategy includes general recommendations and resources for further reading.

The purpose of this slender volume is to describe why and how applied research carried out in a national public health program sometimes influenced program action in the field — and sometimes did not. A number of modified case studies are presented and analyzed to draw some practical lessons and to provide a theoretical basis for future program action. The setting is the Taiwan family planning program. The time period is from the mid 1960’s through the mid 1970’s. The focus is on the productive integration of research findings into community health education programs and the dissemination of these findings to stimulate other Asian countries at earlier stages of program planning and implementation. The viewpoint is that of a former program advisor and community health educator who spent some ten years on site and observed or participated in the events described. The results of quantitative research, particularly operations research and social surveys, recorded documents, and interviews comprise the methodology used to collect data. Aims to describe why and how applied research carried out in a national public health program sometimes influenced program action in the field - and sometimes did not. This title presents and analyses a number of modified case studies to draw some practical lessons and to provide a theoretical basis for future program action.

Can we make sense of the relationship between research and policy? How can policy makers and researchers make better use of research to contribute to more evidence-based policies that reduce poverty, alleviate suffering and save lives? This paper written on behalf of the Overseas Development Institute (ODI) explores the relationship between research and policy. In the context of policy, research has often been ignored, inaccurate or neglected the concerns of poor and marginalised people. Research could have greater impact upon policy than it has had to date. Policy makers could make more extensive use of research and researchers could communicate their findings more effectively: Research may be ignored for a number of reasons. These range from ineffective communication, to the ignorance/anti-intellectualism of politicians. Understanding of the relationship between policy and research needs to be deepened if evidence-based policy making that responds to the demands of poor people is to be promoted. There are various models of policy making. Linear models have now been replaced by incremental and latterly ‘enlightenment’ methods. Contextual analysis and credibility are important dimensions when looking at the impact research has upon policy. In terms of context, both policy makers and researchers are influenced by political, social and economic structures, but more importantly the assumptions that underlie them. In terms of credibility, in aiming for more pro-poor evidence based policy, local involvement and effective dissemination are fundamental. It seems that researchers should have more influence on policy makers, and policy makers could make better use of research: Both research and policy have the obligation to establish chains of legitimacy with their informants. Research is more likely to contribute to evidence-based policy making if it fits within the political and institutional limits of policy makers and resonates with their ideological assumptions. This is also true if outputs are based on credible evidence, and are communicated via the most important communicators.

Evidence of the influence of research on health policy is paradoxical. While there is scant evidence that research has had any impact on the direction or implementation of widespread health reforms, research on evidence-based medicine has dramatically increased, despite limited evidence that it has affected clinical practice. These developments have occurred in the context of a general decline in state intervention and provision and a post-modern questioning of researchers\' authority. Models of the relationship between research and policy range from one where empirical research rationally informs decision-making, through research incrementally affecting policy, to an \"enlightenment\" or \"infiltration\" model, which may operate on a conceptual level. Health research that contributes to large-scale socio-political change may require more methodological pluralism and greater focus on key institutional structures. Case studies reviewed suggest that dissemination is enhanced if researchers involve managers and policy-makers in the development of the framework for and focus of research and if investigators assume a responsibility for seeing their research translated into policy. Public health research is more influential if topical, timely, well-funded and carried out by a collaborative team that includes academics. Evaluations are more influential if, in addition, they are commissioned by health authorities but based on local collection of data, and instruments and incentives to implement policy are available. In some areas, such as the recent policy focus on careers in the community, researchers were largely responsible for raising this policy issue, whereas in other areas, such as the relationship between unemployment and health, researchers are just one of the groups of experts making competing claims about causality. In conclusion, clear research findings are not always a passport to policy, but researchers can reframe the way health policy issues are seen, and collaboration with policy-makers initially can enhance implementation later.

FHI 360 is committed to moving evidence into practice to improve the health and development of the people and communities we serve. We purposefully employ a range of strategies across the research-to-practice continuum to achieve maximum impact. As a global research and implementation organization, FHI 360 is uniquely positioned to implement research utilization.

The knowledge industry must surely be considered one of the majors in the nation. In research and development alone the Federal investment amounts to some $20-billion annually. Curiously, it is an industry where astonishingly little attention has been dedicated to the marketing of its product. In these days of accountability, many persons are asking "How have these products been used to help us?" For example, public interest groups and their Washington lobbyists are formally asking the question with implications of skepticism. But there is a still more compelling reason for defending a more systematic facilitation of knowledge utilization: in human services the well-being of millions of American citizens depends in part on the effectiveness and efficiency of those services. The effectiveness and efficiency, in turn, depend in part upon optimum input of relevant knowledge. The record has it that common influencers of policies and practices are socio-political pressures, personal predilections, and persistence of the way things have been done before. The use of new knowledge trails along behind. There is a responsibility for better knowledge transfer on the parts of both the knowledge producers and the policy and practice people. But how can responsibilities for improved knowledge utilization be carried out? The literature on the topic offers advice. In fact, a surfeit of it. In the past 20 years the number of citations in the knowledge utilization field has grown from some 400 to an estimated 20,000 plup. If you venture into this literature in a quest for guidance, you stagger out reeling. The field abounds with assertions, conceptual models for analysis, and contradictory observations. But sound research information seems to remain in hiding. Dr. Edward Glaser and his colleagues at the Human Interaction Research Institute (HIRI)-Drs. Harold Abelson, Michael McKee, Goodwin Watson, Ms. Kathalee Garrison, and Ms. Molly Lewin-have marshalled an assault, as it were, upon literature. They have ferreted out sounder facts pertaining to the process of knowledge utilization and driven out the seemingly useless materiaL And beyond that, they have distilled the essence of knowledge on knowledge utilization. The result is perhaps not quite a technology manual in itself, but it certainly does represent an orderly presentation of rich information that will be essential to anyone planning and developing better ways of knowledge transfer, From the standpoint of NIMH\'s services research and development program, I should like to point out that HIRI material of this sort has been used as a basis for research utilization policy and practice decisions for eight years. During that time the "utilization rate" of projects has increased eight-fold. In this program alone, it has led to fruitfulness of multiple millions in research investments. We are grateful to HIRI for its signal contribution. We hope others will find this newly revised material to be similarly beneficial.

In clinical practice caring for patients generates many questions about diagnosis, prognosis, and treatment that challenge health professionals to keep up to date with the medical literature. A study of general practitioners in North America found that two clinically important questions arose for every three patients seen.1 The challenge in keeping abreast of the medical literature is the volume of literature. General physicians who want to keep up with relevant journals face the task of examining 19 articles a day 365 days a year.2 One approach to meeting these challenges and avoiding clinical entropy is to learn how to practise evidence based medicine. Evidence based medicine involves integrating clinical expertise with the best available clinical evidence derived from systematic research.3 Individual clinical expertise is the proficiency and judgment that each clinician acquires through clinical experience and practice. Best available clinical evidence is clinically relevant research which may be from the basic sciences of medicine, but especially that derived from clinical research that is patient centred, that evaluates the accuracy and precision of diagnostic tests and prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. This paper focuses on what evidence based medicine is and how it can be practised by busy clinicians. The practice of evidence based medicine is a process of lifelong self directed learning in which caring for patients creates a need for clinically important information about diagnoses, prognoses, treatment, and other healthcare issues. The box at the bottom of the next page illustrates the five steps necessary to the practice of evidence based medicine. Practising evidence based medicine allows clinicians to keep up with the rapidly growing body of medical literature Evidence based medicine improves clinicians\' skills in asking answerable questions and finding the best evidence to answer these questions …

“Scaling up” effective health services is high on the policy agendas of many countries and international agencies. The current concern has been driven by growing recognition both of the challenges of achieving the health-related Millennium Development Goals (MDGs) in many countries, and of the need to ensure that the increased resources for health channelled through disease-specific health initiatives are able generate health gain at scale. Effective and cost-effective interventions exist to address many of the major causes of disease burden in the developing world, but coverage of many of these services remains low. There is a substantial gap between what could be achieved and what is actually being achieved in terms of health improvement in low- and middle-income countries. The term “scaling up” is widely used as shorthand to describe the objective or process of expanding service delivery. As this broad definition suggests, the term scaling up has been used in a variety of ways and contexts. For example, it can refer to the outcome, in terms of increased coverage, or the inputs required, whether financial, human or capital resources. Similarly, scaling up can also refer to a policy, strategy or the process of expansion [1]. The object of scaling up can be particular health interventions (e.g. attended delivery, insecticide treated mosquito nets, or integrated management of childhood illness), or health systems interventions such as health financing mechanisms (community-based health insurance), incentive mechanisms (e.g. pay-for-performance or contracting) or approaches to service delivery (e.g. training shopkeepers to supply antimalarial drugs).

The best use of the conceptual framework is as a comprehensive planning tool. When used as such, it can allow researchers to plan activities to enhance research utilization through the life of the project, and beyond. However, the conceptual framework can also be used once the project has been completed: (i) to identify and analyse the various factors and activities (communication, collaboration, etc.) undertaken during the research process to enhance utilization; or (ii) in cases where research utilization was less than expected, to identify and analyse factors and activities that may have been neglected or inadequately executed. It should be kept in mind that it is often difficult to prove a causal relationship between activities to enhance research utilization and actual utilization. This chapter discusses the factors researchers need to consider during the three main phases of the research process: pre-research, during research and postresearch. Although some factors are discussed individually in relation to a single phase of the research process, in practice they may need to be applied such that the three phases are seen as a single continuum. In applying the activities recommended in the conceptual framework, researchers need to be aware of what they can influence and what they cannot. For example, researchers can influence certain external factors to strengthen research utilization, in particular, by employing effective communication strategies and developing collaborative links with key stakeholders and end users of the research. However, they may not be able to influence such things as the current political, legal or programmatic climate in the country. In this chapter, individual sections discuss factors in each phase of the research process. This is followed by a review of additional parallel processes of stakeholder involvement, communication and macro-contextual factors. The importance of these additional processes is described in the discussion of each stage of the research and scaling-up activities.

The growth of health promotion as a topic for discussion and a principle for practice is widespread, and affects all groups of health professionals. The Healthy Cities project, like Health for All, was inaugurated by the World Health Organization and has informed policy throughout the world. Healthy Cities: Research and Practice examines the application of the project in a number of countries. The contributors explore problems in the relationship between policy makers, communities, and academic researchers, and discuss how the Healthy Cities program affects housing policy, community development, scientific interchange and health education. In addition, the Editors, John Davies and Michael Kelly, provide a context by tracing the history of the WHO projects and discuss them in the broader context of scientific and philosohical debates about modernism and post-modernism. The contributors are drawn from practitioners and scientists with wide experience in the area from the United Kingdom, Canada, Australia and the United States. Healthy Cities will be invaluable to all those working at community level and in government with an interest in health, as well as students of health promotion.

Objectives:
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.

A shift in the culture and practice of health and development research is required to maximise the real-world use of evidence by non-academic or non-research-oriented audiences. Many frameworks have been developed to guide and measure the research utilisation process, yet none have been widely applied. Some frameworks are simplified to an unrealistic linear representation while others are rendered overly complex and unusable in an attempt to capture all aspects of the research utilisation process. Additionally, many research utilisation frameworks have focused on the policy development process or within a clinical setting, with less application of the translation process at the programme level. In response to this gap – and drawing from over a decade of experience implementing research utilisation strategies – we developed a simple, four-phase framework to guide global health and development efforts that seek to apply evidence to policies and programmes. We present a detailed description of each phase in our framework, with examples of its relevance and application illustrated through our own case study experiences in global health. We believe the utility of this framework extends beyond the health sector and is relevant for maximising use of evidence to achieve the Sustainable Development Goals. Keywords: Research utilisation, Evidence-to-practice, Knowledge translation, Knowledge brokers, Research uptake, Evidence-informed policy, Research utilisation framework, Research utilisation case study

The following conceptual framework for research utilization was developed during the course of the WHO and Partners Technical Consultation on Turning Research into Practice (TRIP) held in Geneva, Switzerland, in March 2003, a subsequent TRIP Working Group meeting held in London, United Kingdom, in July 2003 and a TRIP Workshop to Review Case-Studies (held in Johannesburg, South Africa, in June 2004). The development process involved an analysis of definitions and determinants of research utilization, as well as an examination of existing case-studies, conceptual pathways and key elements of research utilization. The utility of the conceptual framework as a tool for documenting and examining research utilization through analysis of case-studies was tested and refined during the June 2004 TRIP Workshop, with input from policymakers, researchers, and programme managers in the field of sexual and reproductive health. The conceptual framework may be applied both prospectively and retrospectively. Prospectively, donors, researchers, or programme managers can use it to assess and potentially influence factors that may enhance research utilization. Retrospectively, it may be used to analyse case-studies (of either success or failure) in order to learn from them. The conceptual framework is intended to be applicable across a range of research domains (e.g. basic, clinical, epidemiological, social science, or operations research), although it is expected that the research questions, stakeholders, communication strategies, and utilization goals may all vary. Although the conceptual framework may be applied prospectively or retrospectively to single research initiatives, in practice it is more productive to use it in the context of a broader body of existing and accumulating research evidence (i.e. a series of 17TRIP related research studies that are contributing, or have contributed, to an applicable body of knowledge). Thus, in some cases, utilization of research may be measured by its contribution to a developing theoretical knowledge base, or by its influence in stimulating further areas for investigation. Finally, although the conceptual framework may be useful for highlighting where further attention to certain factors may be critical to achieve research utilization, it does not necessarily follow that these factors lie within the responsibility or sphere of influence of the researcher. Thus, in such cases, the conceptual framework may be a useful tool for alerting or involving other stakeholders, including donors, government, advocacy groups, policy-makers and programme managers.

(a) The U.S. system is deeply indebted to the extension model developed in the agricultural tradition; (b) it has traditionally focused on the dissemination side of the equation, rather than on the knowledge use side; (c) it has grown up as a set of uncoordinated—and even competitive—activities; (d) the resulting approach is largely top down, research-to-practice focused, rather than bottom up, problem-solving focused. (p. 290) A number of researchers have noted that, while the extension model has worked successfully in the field of agriculture, it has not been particularly effective National Center for the Dissemination of Disability Research (NCDDR) July 1996 4 in other areas. The reasons for this circumstance include issues of funding and coordination; also important are differences in the user orientation of agricultural and other research and in the kinds of information being disseminated. Rogers (1988) points out that agricultural researchers have always geared their work toward farmers’ use of their results. He also notes that the agricultural extension system has been less successful when the subject matter to be disseminated strays from agricultural production technology. The agricultural extension model reflects a rational, linear conception of the process of knowledge utilization; the focus of this model is on getting the word out, with the assumption that good ideas will be used by those who hear about them. As Louis (1992) explains, a key assumption of this approach to dissemination “is that knowledge is a ‘thing’ that simply needs to find a good home” (p. 288). However, the understandings about knowledge use emerging from the recent literature reveal that the process is complex, transactional, and heavily dependent on the potential user’s pre-existing knowledge, beliefs, and experiences. The focus on the user of research has come to the forefront during a period when the target audiences for disability research have broadened to include stronger attention to direct service providers and to persons with disabilities and their families. Although little empirical research has been conducted to assess the effectiveness of specific dissemination approaches with diverse user audiences, it is clear that consideration needs to be given to demographic and psychographic differences. Many improvements have been made in the dissemination of disability research (Blasiotti, 1992). NIDRR and other branches of the federal government are working to establish common perspectives as well as coordinated approaches to dissemination, and to encourage the incorporation of dissemination into all stages of the research, development, and utilization process. This literature review, along with a series of guides to effective practice that will be developed from it, is intended to support such changes.

This paper is based on the proposition that transfer of knowledge between researchers and practitioners concerning effective health promotion interventions is less than optimal. It considers how evidence concerning effectiveness in health promotion is established through research, and how such evidence is applied by practitioners and policy makers in deciding what to do and what to fund when addressing public health problems. From this examination it is concluded that there are too few rewards for researchers which encourage research with potential for widespread application and systematic development of promising interventions to a stage of field dissemination. Alternatively, practitioners often find themselves in the position of tackling a public health problem where evidence of efficacy is either lacking, or has to be considered alongside a desire to respond to expressed community needs, or the need to respond to political imperative. Several different approaches to improving the fit between research and practice are proposed, and they include improved education and training for practitioners, outcomes focussed program planning, and a more structured approach to rewarding research development and dissemination.

The Community-based Health Planning and Services (CHPS) initiative in Ghana is an example of a strategy for scaling up a field trial to become a national programme. Representing a response to the problem that research projects can inadvertently produce nonreplicable service delivery capabilities, CHPS develops mechanisms for expanding national understanding and use of research findings to serve the health service needs of all Ghanaian households. This chapter describes strategies for introducing and developing community health services that were successfully tested in a Navrongo Health Research Centre trial and validated in Nkwanta District for a national programme of reorienting primary health care from clinics to communities. Nurses, once confined to clinical duties, are relocated to community-constructed clinics where they live and work. Volunteers support their services by mobilizing traditional social institutions to foster community support. Strategies for decentralized planning ensure that operational details of the programme are adapted to local circumstances. Strengths and limitations of the programme are reviewed and discussed.

The relationship between research and health policy is discussed from a policy process perspective, describing communication problems in the course of policy formulation, implementation and evaluation. Policy process is often expected by researchers to be rational, having logical sequence of steps and the objective evaluation of alternatives based on scientific knowledge. In fact, policies are often formulated without clear problem identification or based on wrong assumption. The timing of research and policy-making differs. Policy-makers need to respond quickly. Evaluations may be regarded by politicians as embarrassing if they point to a need for significant change. It is not satisfactory to consider only research and policy-making: their relationship is influenced by the media, different interest groups and by the general public. Health policy formulation is embedded in the general policy environment of particular societies. Some countries have a long tradition of consensus-building, while in others health reforms have been formulated and introduced in a centralized way. Traditional bio-medical thinking influences health policy-makers. The importance of social and political acceptability tends to be overlooked. The paper emphasizes that we are experiencing an era of scarcity of resources and growing tension concerning allocation decisions. Existing institutions provide insufficient incentives for policy-makers and researchers to promote public dialogue about such issues. The paper concludes that there is a need for new approaches to policy development and implementation, new structures in policy-making, changes in research financing and co-operation between disciplines and new structures for public participation in policy-making. Research should facilitate more open and democratic dialogue about policy options and the consequences of alternative choices.

This chapter describes two initiatives that have utilized research to guide the development and scaling up of community-based health and family planning programmes. In Bangladesh and Ghana, evidence was accumulated in stages, beginning with an exploratory investigation, followed by an experimental trial testing potential interventions and a replication phase for validating research results in a non-research programme setting. The process concluded with research-guided programme expansion. Each stage was associated with shifts in generations of questions, mechanisms and outcomes as the process unfolded. Large-scale health systems development was achieved in both countries, not because the scaling-up strategies were alike but because similar research approaches led to different strategies adapted to contrasting societal and institutional contexts

Despite improved supply of health care services in low-income countries in the recent past, their uptake continues to be lower than anticipated. This has made it difficult to scale-up those interventions which are not only cost-effective from supply perspectives but that might have substantial impacts on improving the health status of these countries. Understanding demand-side barriers is therefore critically important. With the help of a case study from Nepal, this commentary argues that more research on demand-side barriers needs to be carried out and that the stated-preference (SP) approach to such research might be helpful. Since SP techniques place service users' preferences at the centre of the analysis, and because preferences reflect individual or social welfare, SP techniques are likely to be helpful in devising policies to increase social welfare (e.g. improved service coverage). Moreover, the SP data are collected in a controlled environment which allows straightforward identification of effects (e.g. that of process attributes of care) and large quantities of relevant data can be collected at moderate cost. In addition to providing insights into current preferences, SP data also provide insights into how preferences are likely to respond to a proposed change in resource allocation (e.g. changing service delivery strategy). Finally, the SP-based techniques have been used widely in resource-rich countries and their experience can be valuable in conducting scaling-up research in low-income countries.

One important first step is clarifying terms used, almost interchangeably, in research utilization, as it incorporates a range of ways in which research can be used for making decisions to strengthen RH/FP policies and programs. (Concepts underlying terms used are defined in Box 1.) Achieving, and measuring, utilization of research depends in part on what type(s) of utilization is envisioned, and so it is critical the specific type needs to be considered and specified before research begins. Box 1. Clarifying Research Utilization Language Research utilization: making decisions concerning policy, advocacy and resource allocation, planning and management, and program systems development and strengthening, using information generated from research. Institutionalization: incorporation of a practice or intervention proven to be effective (sometimes termed a ‘best practice’) within the routine activities of a facility, program or organization. Replication: introduction of a proven intervention or practice into another setting; this may be another program or another country. Scale-up: extension of an intervention or proven practice beyond the original project site. Moreover, an OR project may be expected to achieve several types of utilization, depending on project nature, generalizability of findings to other programs and settings, and availability of resources for more than one type of utilization. For example, an intervention proven successful in a district may first become institutionalized within that district’s health program and then scaled up to other districts in the same province and to other provinces. If appropriate, it may also be replicated in another country. Most of the principles described below are relevant whether research concerns introduction of a new or improved RH/FP technology to a country or program (such as emergency contraception), or of a new / revised service delivery guideline or tool (such as the Balanced Counseling Strategy or Systematic Screening or an educational or training curriculum), or the reorganization of service delivery systems (such as integrating FP with HIV services, or using community‐level workers to provide services usually offered in clinics).

This manual for researchers is based on the premise that research can have the greatest impact on policies and programs when effective communication exists among researchers decision-makers and the affected community. It follows that steps can be taken during the design and implementation of research projects to systematically encourage effective communication from the beginning. The four basic stages in a research process (defining the question developing the proposal conducting the study and communicating results) serve as a framework for recommendations that focus attention from the start on the desired impact of the research. Using this framework the manual considers how researchers can 1) involve decision-makers program managers front-line workers and intended beneficiaries in identifying research needs and reviewing proposals and plans; 2) develop a relationship of trust with those involved in policies and programs and with beneficiaries; 3) involve program staff and community members in data collection and analysis; 4) review research progress periodically with these stakeholders; 5) involve managers staff and communities in drawing conclusions and making recommendations; 6) focus research reports on specific program and policy issues; 7) suggest specific actions based on findings; 8) prepare different types of reports and presentations for different audiences; and 9) use time effectively and strategically.

Evidence based therapies that prevent morbidity or death are often not translated into clinical practice. One reason is that research often neglects how to deliver therapies to patients.1 Consequently, errors of omission are prevalent and cause substantial preventable harm.2 Attempts to increase the reliable use of evidence based therapies have generally focused on changing doctors’ behaviour.3 However, doctors work in a healthcare team within a larger hospital system, which must be considered when attempting to improve the reliability of patient care. Models to increase the reliable use of evidence based therapies typically focus on translating evidence into practice or on the best methods to run a collaborative; few if any have done both.4 Our model embeds an explicit method for knowledge translation in a collaborative model for broader dissemination of knowledge into practice. Model to translate evidence into practice We have described an integrated approach to improve the reliability of care5 that has been associated with substantial and sustained reductions in bloodstream infections associated with central lines.6 The approach has five key components: A focus on systems (how we organise work) rather than care of individual patients Engagement of local interdisciplinary teams to assume ownership of the improvement project Creation of centralised support for the technical work Encouraging local adaptation of the intervention Creating a collaborative culture within the local unit and larger system. This approach has matured into the Johns Hopkins Quality and Safety Research Group translating evidence into practice model (figure⇓). The resources required to develop, implement, and evaluate programmes using this model are substantial

Because public health must operate at scale in widely diverse, complex situations, randomized controlled trials (RCTs) have limited utility for public health. Other methodologies are needed. A key conceptual backbone is a detailed ‘‘theory of change’’ to apply appropriate evidence for each operational component. Synthesizing patterns of findings across multiple methodologies provides key insights. Programs operating successfully across a variety of settings can provide some of the best evidence. Challenges include judging the quality of such evidence and assisting programs to apply it. WHO and others should shift emphasis from RCTs to more relevant evidence when assessing public health issues.

SIE has compiled and organized hundreds of articles, papers, books, and other resource on scaled social impact. With our shift in strategy to systems change, we have amassed a collection of resources on this and related topics that we are continuously building.

This paper is about the relationship between research and policy – specifically about how research impacts on policy, and about how policy draws on research. It might be thought that the relationship is straightforward, with good research designed to be relevant to policy, and its results delivered in an accessible form to policy-makers – and with good policy-making securely and rationally based on relevant research findings. In fact, this is far from the case. As a taster, Box 1 gives ten reasons why the link from research to policy might not be straightforward. Sometimes research is not designed to be relevant to policy. Sometimes it is so designed, but fails to have an impact because of problems associated with timeliness, presentation, or manner of communication. Sometimes (probably quite often) policy-makers do not see research findings as central to their decision-making. The relationship between research and policy is often tenuous, quite often fraught. To observe as much is not new. There are literatures on the question in many social science disciplines – in political science, sociology, anthropology, and management, to name a few. Our purpose here is to review some of these literatures and to draw out the implications for both researchers and policy-makers.1 The starting point is a discussion of what is meant by ‘policy’ and the ‘policy process’. The rational, linear model of policymaking – which summarises a logical sequence from problem definition, through analysis of alternatives, to decision, implementation, and review – is the traditional approach. We will see shortly what is wrong with this. Accordingly, the paper begins (Section 2) with a brief review of thinking on policy, presenting alternative models, and setting out a framework for thinking about the interaction between research and policy. It then deals successively with the challenge facing researchers (Section 3) and policy-makers (Section 4). Can the range of advice already offered to researchers be extended? And can policymakers be helped by new ideas such as evidence-based policy-making and performancebased evaluation? The Conclusion (Section 5) draws these threads together, suggesting that the impact of research is uncertain and contingent on social and political context.

The complex evidence-policy interface in low and middle income country settings is receiving increasing attention. Future Health Systems (FHS): Innovations for Equity, is a research consortium conducting health systems explorations in six Asian and African countries: Bangladesh, India, China, Afghanistan, Uganda, and Nigeria. The cross-country research consortium provides a unique opportunity to explore the research-policy interface. Three key activities were undertaken during the initial phase of this five-year project. First, key considerations in strengthening evidence-policy linkages in health system research were developed by FHS researchers through workshops and electronic communications. Four key considerations in strengthening evidence-policy linkages are postulated: development context; research characteristics; decision-making processes; and stakeholder engagement. Second, these four considerations were applied to research proposals in each of the six countries to highlight features in the research plans that potentially strengthen the research-policy interface and opportunities for improvement. Finally, the utility of the approach for setting research priorities in health policy and systems research was reflected upon. These three activities yielded interesting findings. First, developmental consideration with four dimensions – poverty, vulnerabilities, capabilities, and health shocks – provides an entry point in examining research-policy interfaces in the six settings. Second, research plans focused upon on the ground realities in specific countries strengthens the interface. Third, focusing on research prioritized by decision-makers, within a politicized health arena, enhances chances of research influencing action. Lastly, early and continued engagement of multiple stakeholders, from local to national levels, is conducive to enhanced communication at the interface. The approach described has four main utilities: first, systematic analyses of research proposals using key considerations ensure such issues are incorporated into research proposals; second, the exact meaning, significance, and inter-relatedness of these considerations can be explored within the research itself; third, cross-country learning can be enhanced; and finally, translation of evidence into action may be facilitated. Health systems research proposals in low and middle income countries should include reflection on transferring research findings into policy. Such deliberations may be informed by employing the four key considerations suggested in this paper in analyzing research proposals.

Discovering ways to increase access to and delivery of interventions is a major challenge. Typically research is divorced from implementation, which has led to a growing literature about how to get research into practice. However, operational research is best prioritized, designed, implemented and replicated from within national programmes. The current model for most international health service research is based on the assumption that the research community “discovers” solutions and then tries to market them to busy decision-makers and practitioners. The problem of failing to get research into policy and practice is well known. Much debate focuses on the effectiveness of different approaches to dissemination and behaviour change.1–4 This is a significant issue when trying to influence individual practitioners. Another focus is on developing the capacity of research institutions in developing countries, with the expectation that this will increase the relevance and local ownership of results.5 We argue that these two approaches are necessary but not sufficient. The aim should not be to perfect techniques of feeding results to decision-makers, but to start from the perspective of the decision-makers even before devising the questions. This means “getting practice into research”. This approach is not appropriate for research into new and untried treatments where efficacy has not been established, but should become the norm for operational research, by which we understand research into how an intervention is implemented. It is an approach that is gaining ground in the developed north, but which has even greater application in resource-constrained settings. Here, based on our experience in China, Pakistan and elsewhere, are some key considerations: Operational research should be embedded in local programmes. Operational research should emerge out of an ongoing partnership with a national programme. This includes the process of prioritizing, developing, conducting and disseminating research, and is part of national expansion of services. Operational research should focus on local opportunities for going to scale. The first stage is to explore the options that are under consideration for implementation and then design research to inform the choice of how that implementation should best be carried out. For maximum effect, it is often useful to focus attention on situations where there are resources available from international or national agencies, but where some technical or organizational block has prevented them from being used effectively. The research questions may be based on an understanding of the barriers to large-scale access. 6 Then trials and social and economic studies can be embedded within programme sites, and provide knowledge on how to overcome these barriers and deliver effective interventions, as in Pakistan.7–9 Because these operational issues are commonly relevant to other high-burden countries, the publication of the results should have international as well as national influence.

Bridging the know–do gap is one of the most important challenges for public health in this century. It also poses the greatest opportunity for strengthening health systems and ultimately achieving equity in global health. Knowledge translation (KT) is emerging as a paradigm to learn and act towards closing the gap. While knowledge is more than research evidence, knowledge translation strategies can harness the power of scientific evidence and leadership to inform and transform policy and practice. There are pioneering efforts as well as exciting new initiatives in various developed and developing countries with respect to knowledge translation. Countries (policy-makers, health workers, researchers and the community) can work together and share experiences and lessons in bridging the gap. Although there are ongoing innovations and learning by doing, there is still no comprehensive framework or common platform for better understanding the know–do gap and systems to address it. WHO has a major role to play in bridging the know–do gap and supporting countries through better knowledge management. Given the breadth and scope of this great challenge, WHO should focus on the following: strategic advocacy for KT; platforms for knowledge exc change and sharing among countries and within WHO; resource mobilization; support country initiatives on KT strategies for health systems strengthening. For countries and the global community alike, some initial recommendations for action are: capacity development for KT, focusing on knowledge exchange and demand-side awareness-building; joint learning platforms for KT; research on improved methodologies for knowledge synthesis and exchange, and best practices on KT; KT-sensitive peer review and funding systems.

This document is the outcome of two meetings. The first meeting reviewed case-studies and other evidence related to research utilization from the standpoint of researchers and donors, while the second meeting reviewed additional materials from the standpoint of policy-makers and sexual and reproductive health programme managers. It is hoped that the information in this document will not only help researchers and others to increase the utilization of research findings, but also help them to monitor the extent to which research-based evidence is used for policy change and adoption of best practices to improve sexual and reproductive health. Findings from well-designed and ethically sound research should contribute to the formulation of policies and the development and strengthening of programmes for improving the sexual and reproductive health and well-being of communities. In order to ensure maximum utilization of research findings, researchers need to be adept in a range of communication skills and information dissemination strategies, including the ability to identify and engage with relevant stakeholders. For their part, policy-makers and service providers need to have a sound appreciation of how research can contribute to the development and modification of policies and practices, including implementation of interventions. A key obstacle to the utilization of research is the lack of dialogue between the various stakeholders. The gap between knowledge generation and its use is now well recognized by many researchers, donors, policy-makers and service providers. The challenge before all stakeholders is how to develop strong communication linkages between the various parties in order to facilitate the uptake of research findings. To do this effectively, stakeholders will need to identify the barriers to communication and learn from successful examples of research utilization. Research findings can contribute greatly to improving the reproductive health of people. Findings can be used to make decisions on new policies about provision of services (e.g. instituting new procedures, practices and interventions, including those for prevention) related to reproductive health-care delivery. They can equally contribute to the strengthening of existing programmes in terms of discontinuing practices found to be ineffective or harmful. Furthermore, research findings can also be used for advocacy for reproductive health or promoting the adoption of necessary interventions or for models of best practice to prevent or mitigate consequences of risks to health.

Background
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.

Background
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.

Many reform initiatives in developing countries fail to achieve sustained improvements in performance because they are merely isomorphic mimicry—that is, governments and organizations pretend to reform by changing what policies or organizations look like rather than what they actually do. In addition, the flow of development resources and legitimacy without demonstrated improvements in performance undermines the impetus for effective action to build state capability or improve performance. This dynamic facilitates “capability traps” in which state capability stagnates, or even deteriorates, over long periods of time even though governments remain engaged in developmental rhetoric and continue to receive development resources. How can countries escape capability traps? We propose an approach, Problem-Driven Iterative Adaptation (PDIA), based on four core principles, each of which stands in sharp contrast with the standard approaches. First, PDIA focuses on solving locally nominated and defined problems in performance (as opposed to transplanting preconceived and packaged “best practice” solutions). Second, it seeks to create an authorizing environment for decision-making that encourages positive deviance and experimentation (as opposed to designing projects and programs and then requiring agents to implement them exactly as designed). Third, it embeds this experimentation in tight feedback loops that facilitate rapid experiential learning (as opposed to enduring long lag times in learning from ex post “evaluation”). Fourth, it actively engages broad sets of agents to ensure that reforms are viable, legitimate, relevant, and supportable (as opposed to a narrow set of external experts promoting the top-down diffusion of innovation).

The benefits of integrating programmes that emphasize specific interventions into health systems to improve health outcomes have been widely debated. This debate has been driven by narrow binary considerations of integrated (horizontal) versus non-integrated (vertical) programmes, and characterized by polarization of views with protagonists for and against integration arguing the relative merits of each approach. The presence of both integrated and non-integrated programmes in many countries suggests benefits to each approach. While the terms \'vertical\' and \'integrated\' are widely used, they each describe a range of phenomena. In practice the dichotomy between vertical and horizontal is not rigid and the extent of verticality or integration varies between programmes. However, systematic analysis of the relative merits of integration in various contexts and for different interventions is complicated as there is no commonly accepted definition of \'integration\'-a term loosely used to describe a variety of organizational arrangements for a range of programmes in different settings. We present an analytical framework which enables deconstruction of the term integration into multiple facets, each corresponding to a critical health system function. Our conceptual framework builds on theoretical propositions and empirical research in innovation studies, and in particular adoption and diffusion of innovations within health systems, and builds on our own earlier empirical research. It brings together the critical elements that affect adoption, diffusion and assimilation of a health intervention, and in doing so enables systematic and holistic exploration of the extent to which different interventions are integrated in varied settings and the reasons for the variation. The conceptual framework and the analytical approach we propose are intended to facilitate analysis in evaluative and formative studies of-and policies on-integration, for use in systematically comparing and contrasting health interventions in a country or in different settings to generate meaningful evidence to inform policy.

This paper has focused on some of the defences and barriers to organisational learning that face many NGOs. It has offered some initial pointers and examples of how these can be worked with. The intention has been to open up a conversation and further inquiry into this key area of organisational life, out of which new meanings and actions may emerge. The approach to learning conveyed in this paper inevitably challenges the dominant world view that outcomes need to be predicted and, we are judged solely by our ability to achieve these predetermined outcomes. This is not a conducive environment for learning. Whereas, if we inhabit a world view, where things are not in our control, where we do the best we can, at that moment, but even when we bring all our collective intelligence to bear, things may still not turn out the way we thought, where we operate from a position of humility and compassion for human frailty (including our own) then it offers a very different environment for learning. We need to recognise and work with the barriers to organisational learning, in order to release the vital benefits that it brings. Indeed being able to work with some of the ‘stuckness’ is one part of what organisational learning is about. It takes a strong belief in learning to make a case for funding support/procedures and an organisational culture to support it, for both NGOs and their partners. We hope this paper encourages this.

Adaptive programming and management principles focused on learning, experimentation, and evidence-based decision making are gaining traction with donor agencies and implementing partners in international development. Adaptation calls for using learning to inform adjustments during project implementation. This requires information gathering methods that promote reflection, learning, and adaption, beyond reporting on pre-specified data. A focus on adaptation changes traditional thinking about program cycle. It both erases the boundaries between design, implementation, and evaluation and reframes thinking to consider the complexity of development problems and nonlinear change pathways.Supportive management structures and processes are crucial for fostering adaptive management. Implementers and donors are experimenting with how procurement, contracting, work planning, and reporting can be modified to foster adaptive programming. Well-designed monitoring, evaluation, and learning systems can go beyond meeting accountability and reporting requirements to produce data and learning for evidence-based decision making and adaptive management. It is important to continue experimenting and learning to integrate adaptive programming and management into the operational policies and practices of donor agencies, country partners, and implementers. We need to devote ongoing effort to build the evidence base for the contributions of adaptive management to achieving international development results.

In choosing an evidence-based intervention you may have to make changes to increase fit or compatibility with your audience and/or community. Here is general guidance in terms of things that can and cannot be changed from the original intervention. Remember to refer to any adaptation suggestions from the original developer(s) in making these adaptation decisions.

Objectives:
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.

This article examines issues and challenges in the design of cultural adaptations that are developed from an original evidence-based intervention (EBI). Recently emerging multistep frameworks or stage models are examined, as these can systematically guide the development of culturally adapted EBIs. Critical issues are also presented regarding whether and how such adaptations may be conducted, and empirical evidence is presented regarding the effectiveness of such cultural adaptations. Recent evidence suggests that these cultural adaptations are effective when applied with certain subcultural groups, although they are less effective when applied with other subcultural groups. Generally, current evidence regarding the effectiveness of cultural adaptations is promising but mixed. Further research is needed to obtain more definitive conclusions regarding the efficacy and effectiveness of culturally adapted EBIs. Directions for future research and recommendations are presented to guide the development of a new generation of culturally adapted EBIs.

There is a growing recognition of the value of measuring fidelity of implementation (FOI) as a necessary part of evaluating interventions. However, evaluators do not have a shared conceptual understanding of what FOI is and how to measure it. Thus, the creation of FOI measures is typically a secondary focus and based on specific contexts and programs. This article describes a project that holds the development of FOI measures as its primary goal and has developed a suite of data collection tools designed to be used across multiple programs. It describes the foundation of the suite—a conceptual framework for clearly and specifically describing FOI and the need for the framework. It also describes where the framework resides in existing literature and how it can be used to support measurement of interventions in education and other fields.

In the past few decades, prevention scientists have developed and tested a range of interventions with demonstrated benefits on child and adolescent cognitive, affective, and behavioral health. These evidence-based interventions offer promise of population-level benefit if accompanied by findings of implementation science to facilitate adoption, widespread implementation, and sustainment. Though there have been notable examples of successful efforts to scale up interventions, more work is needed to optimize benefit. Although the traditional pathway from intervention development and testing to implementation has served the research community well—allowing for a systematic advance of evidence-based interventions that appear ready for implementation—progress has been limited by maintaining the hypothesis that evidence generation must be complete prior to implementation. This sets up the challenging dichotomy between fidelity and adaptation and limits the science of adaptation to findings from randomized trials of adapted interventions. The field can do better. This paper argues for the development of strategies to advance the science of adaptation in the context of implementation that would more comprehensively describe the needed fit between interventions and their settings, and embrace opportunities for ongoing learning about optimal intervention delivery over time. Efforts to build the resulting adaptome (pronounced “adapt-ohm”) will include the construction of a common data platform to house systematically captured information about variations in delivery of evidence-based interventions across multiple populations and contexts, and provide feedback to intervention developers, as well as the implementation research and practice communities. Finally, the article identifies next steps to jumpstart adaptome data platform development.

Advocate for the support of M&E of SBC interventions that capture the unpredictability of the change process and reflect the realities of project implementation. Show that proven M&E methods that are appropriately adaptive in response to emergent needs and opportunities can help monitor complexity. Argue that M&E methods that do not address the complexity of both behavior and of program implementation can distort our understanding of SBC Support the claim that data gathered through community feedback and iteration not only can accelerate individual behavior change, but can propel social change. Champion the use of participatory, narrative, mixed methods and learning-based approaches that align with what we know about the context and complexity of SBC program implementation.

If private markets can produce the iPhone, why can’t aid organizations create and implement development initiatives that are equally innovative and sought after by people around the world? The key difference is feedback loops. Well-functioning private markets excel at providing consumers with a constantly improving stream of high-quality products and services. Why? Because consumers give companies constant feedback on what they like and what they don’t. Companies that listen to their consumers by modifying existing products and launching new ones have a chance of increasing their revenues and profits; companies that don’t are at risk of going out of business. Is it possible to create analogous mechanisms that require aid organizations to listen to what regular citizens want—and then act on what they hear? This essay (part first-person account, part research and analysis) argues that the answer is yes. I first look at the current mental model in development, in which experts are largely responsible for determining which projects are implemented and for evaluating the impact of those projects. Partly because of information problems and partly because of incentives, this approach results in slow innovation and little responsiveness to what citizens really want. I then review the potential for new approaches such as randomized controlled trials, concluding that their applicability (and even desirability) is limited for cost, technical, and theoretical reasons. I conclude (along with others such as Pritchett, Samji, Hammer, Woolcock, and Easterly), that only approaches that provide a faster and more steady stream of information from varied sources—especially citizens—are likely to improve the quality of aid. In the future, the default model should be that aid agencies need to demonstrate (a) why they believe regular citizens actually want each proposed project and (b) how citizen voice will be used to ensure high-quality implementation. Rather than creating an immediate mandate, however, the best approach in the near term may be to find out what works and then gradually phase in a series of requirements. Fortunately, many examples have emerged in which direct feedback from citizens has been solicited as input into both the selection and the implementation of development initiatives. Not all have been successful, but some have led to significant improvements in outcomes. Being successful—having a closed feedback loop—requires not only that citizens be listened to but that their voices be acted upon in the form of changes to aid programs. The essay provides a set of principles that can be used by practitioners to design feedback loops with a higher probability of success. It also provides a set of key conceptual issues that remain to be explored in depth by researchers, as well as a potential implementation road map for leaders of aid agencies.

Influenced by a wealth of research and emerging international consensus, key donors including UK Department for International Development (DFID), USAID and the World Bank are encouraging the increased use of adaptive programme approaches to address complex development challenges such as institutional reform and work in fragile and conflict affected states, in an attempt to increase impact. Donors and service providers are however grappling with the complex practicalities of how to design, implement and monitor adaptive programmes – a challenge compounded by the recognised lack of practical case study material to draw on. This paper has been produced jointly by two DFID-funded programmes – LASER (Legal Assistance for Economic Reform) and SAVI (State Accountability and Voice Initiative, Nigeria). Both programmes have been taking an adaptive approach to delivering development support for some time, and are achieving results. Although LASER and SAVI are very different – including in size of budget, sector, location, and aid modality – both deal with significant issues of institutional change in complex environments. It is striking that despite programmatic differences, key aspects of their respective approaches to adaptive programming, as well as many lessons and challenges, are similar. As a contribution to current thinking and practice, this joint paper provides on overview of LASER and SAVI’s practical experience as suppliers and practitioners in designing, contracting, managing, implementing and monitoring flexible, adaptive programmes – complementing the more widely available perspective of academics and think tanks.

CARE Cooperative for Assistance and Relief Everywhere CSO Civil society organization DFID Department for International Development DRC Democratic Republic of Congo GEM Gendered enterprise and markets IRC International Rescue Committee LDP Law and development partnership LSE London School of Economics and Political Science M&E Monitoring and evaluation MEL Monitoring, evaluation, and learning MCP Multi-country programme NGO Non-government organization ODI Overseas Development Institute PbR Payment by results PDIA Problem-driven iterative adaptation PMEL Planning, monitoring, evaluation, and learning PMU Programme Management Unit RCDA Rural Communities Development Agency RTE Real-time evaluation Sida Swedish International Development Cooperation Agency SNA Social network analysis ToC Theory of change USAID United State Agency for International Development 6 Managing to Adapt: Analysing adaptive management for planning, monitoring, evaluation, and learning EXECUTIVE SUMMARY Adaptive management is at the heart of ‘doing development differently’ (Wild et al., 2016). Whether it is here to stay depends on how much it is mainstreamed into existing development programming by donors and implementers alike, especially in planning, monitoring, evaluation, and learning (PMEL) cycles. In this report, we find that mainstreaming adaptive management in PMEL involves three strategies: 1. planning for flexibility; 2. developing locally owned monitoring and evaluation (M&E); and 3. creating an enabling environment for learning. Adopting these strategies contributes to virtuous cycles of PMEL

CLA Collaborating, Learning, and Adapting CoP Community of Practice EB4CLA Evidence Base for CLA ICT Information and Communication Technology IP Implementing Partner IR Intermediate Result KM Knowledge Management M&E Monitoring and Evaluation NGOs Non-governmental Organizations PPL USAID’s Bureau of Policy, Planning, and Learning TOC Theories of Change USAID/PPL United States Agency for International Development Bureau of Policy, Planning, and Learning

Background
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.

Evidence-based public health translation of research to practice is essential to improve the public’s health. Dissemination and implementation researchers have explored what happens once practitioners adopt evidence-based interventions (EBIs) and have developed models and frameworks to describe the adaptation process. This scoping study identified and summarized adaptation frameworks in published reports and grey literature. We followed the recommended steps of a scoping study: (a) identifying the research question; (b) identifying relevant studies; (c) selecting studies; (d) charting the data; (e) collating, summarizing, and reporting the results; and (f) consulting with experts. We searched PubMed, PsycINFO, PsycNET, and CINAHL databases for articles referencing adaptation frameworks for public health interventions in the published and gray literature, and from reference lists of framework articles. Two reviewers independently coded the frameworks and their steps and identified common steps. We found 13 adaptation frameworks with 11 program adaptation steps: (a) assess community, (b) understand the EBI(s), (c) select the EBI, (d) consult with experts, (e) consult with stakeholders, (f) decide on needed adaptations, (g) adapt the original EBI, (h) train staff, (i) test the adapted materials, (j) implement the adapted EBI, and (k) evaluate. Eight of these steps were recommended by more than five frameworks: #1–3, 6–7, and 9–11. This study is the first to systematically identify, review, describe, and summarize frameworks for adapting EBIs. It contributes to the literature by consolidating key steps in program adaptation of EBIs and describing the associated tasks in each step.

At Abdou Moumouni University in Niamey, Niger, the Evidence to Action (E2A) Project partnered with stakeholders in the government and university to successfully: - Equip thousands of students with the knowledge, skills, and resources they need to become agents of change. - Build the capacity of providers to meet students’ reproductive health needs, including a full range of contraceptive options. - Make this progress sustainable. This University Leadership for Change initiative was so effective, we scaled it up to universities in Zinder, Maradi, and Tahoua—and didn’t stop there. As part of the Resilience in Sahel Enhanced-Family Planning (RISE-FP) Project, we joined local partners to adapt our approach to reach young people in a challenging new environment: rural communities in Zinder. Now you can get insights from our adaptation experience and see the innovative tools E2A produced in partnership with Syntegral and used to deliver results, including a 30% increase in new family planning acceptors among young people.

From 2014 to 2016, the USAID-funded Evidence to Action (E2A) Project implemented the University Leadership for Chance (ULC) project in Niger to promote youth leadership and strengthen health systems to meet family planning and reproductive health (FP/RH) needs. From 2017 to 2019, E2A and partner Syntegral adapted this project to the community setting and implemented it as Community Leadership for Change (CLC) as part of the Resilience in the Sahel Enhanced-Family Planning (RISE-FP) program. E2A and Syntegral developed a set of tools for adapting programs to different contexts to systematically identify needs for adaptation and monitor implementation of these changes in the RISE-CLC project. This report describes the use of the Context of Implementation and Adaptation (COIA) Analysis and Frontline Aggregated Monitoring and Evaluation (FrAME) Adaptive Management System tools throughout project implementation.

Background
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.

This chapter examines the potential role for an intermediate tier in diffusing innovations and finishes with a discussion of themes and ideas. It focuses on the phrase 'the diffusion of innovations' is used inclusively to incorporate the diffusion of newly developed and tested products and technologies; newly trialled drugs, materials and techniques in health care and also new practices, services or care pathways. The chapter argues for a redirection of attention and resources towards facilitating the diffusion of the numerous innovations which are produced from within the broader health care system. It explores innovation diffusion and application and concluded with a proposed focus on resource-based view (RBV) of the firm, as potentially useful in health care. The RBV focuses on effective management of knowledge to promote innovation and competitive advantage and increase a firm's ability to respond to threats in the external environment.

In practical terms, that means individuals, groups, organisations and networks need to invest in enhanced capabilities to: specify interventions that are relevant to context, drawing on insights of those in that context implement interventions in ways that support the ongoing and real-time sensing of information, insights and ideas from the internal organisational system, from partners and peers, and most importantly from communities and others embedded in operational contexts; make sense of this information, insights and ideas in ways that is relevant for the programme or policy, to support more appropriate, contextually relevant decision making make appropriate changes and adjustments at a strategic and tactical level. Do all of the above on an ongoing basis, in continuous cycles of ‘learning by doing’. At a minimum, aid organisations that addressed the adaptation gap would,: Operate from the “end-user-back”, and not from the “organisation-forward” Develop knowledge, information and data capabilities and tools to anticipate and interpret problems, emerging needs, and to respond to uncertainty and change Empower organisations and teams to make decentralized decisions based on a shared understanding of organizational purpose and values Foster new kinds of networks and partnerships to achieve goals in a highly collaborative fashion Develop and adapt business models as necessary to ensure relevance in a highly fluid and dynamic world

Purpose
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.

ADAPT Analysis Driven Agile Programming Techniques CLA Collaborating, Learning, and Adapting CoP Community of practice DAC Development Assistance Committee DFAT Australian Department of Foreign Affairs and Trade DFID UK Department for International Development EB4CLA Evidence Base for CLA GIZ German Federal Enterprise for International Cooperation ICT Information and Communication Technology IDB Inter-American Development Bank IRC International Rescue Committee KM Knowledge management M&E Monitoring and evaluation NGO Nongovernmental organization PPL USAID’s Bureau of Policy, Planning, and Learning SIDA Swedish International Development Agency SRH Self-rated health TOC Theories of Change USAID/PPL United States Agency for International Development Bureau of Policy, Planning, and Learning

The challenges to economic, social and political development are complex and, therefore, unpredictable (Ramalingam and Jones, 2008). As many commentators have argued, effective programming by governments, non-governmental organisations and international agencies requires a shift in emphasis – moving away from a heavy reliance on planning and ex-ante analysis towards monitoring, learning and adaptation (Jones, 2011). How, then, can policy makers, managers and practitioners best plan in the face of complexity? Does complexity make planning an irrelevant exercise? This background note is a guide, elaborating how planning and strategy development can be carried out despite complexity. While it is true that complex situations require a greater focus on learning and adaptation, this does not render planning irrelevant. In fact, there are ways in which the processes and products of planning can respect the realities of the situation and set up interventions (policies, programmes and projects) to give them the best chance of success. The guide builds on academic, policy and programmatic literature related to themes around systems and complexity (such as an in-depth study by Jones, 2011, which synthesises much of the material), and draws on the authors’ experience of advising development agencies and governments in both developed and developing countries. First, this guide describes the features of complex situations, and explains why they pose a challenge for traditional planning approaches. This should give the reader the necessary tools to assess whether and in what way they are facing a complex problem (and, therefore, whether the guide is relevant for them). Second, it outlines key principles for planning in the face of complexity. This should give the reader an understanding of how planning and strategy development need to differ from more traditional approaches when confronted by complex problems. Third, the guide provides examples of approaches that have been used for planning in situations of complexity. This should give the reader a deeper understanding of the principles involved, and some ideas about how they can be applied in practice

There are increasing criticisms of dominant models for scaling up health systems in developing countries and a recognition that approaches are needed that better take into account the complexity of health interventions. Since Reform and Opening in the late 1970s, Chinese government has managed complex, rapid and intersecting reforms across many policy areas. As with reforms in other policy areas, reform of the health system has been through a process of trial and error. There is increasing understanding of the importance of policy experimentation and innovation in many of China’s reforms; this article argues that these processes have been important in rebuilding China’s health system. While China’s current system still has many problems, progress is being made in developing a functioning system able to ensure broad population access. The article analyses Chinese thinking on policy experimentation and innovation and their use in management of complex reforms. It argues that China’s management of reform allows space for policy tailoring and innovation by sub-national governments under a broad agreement over the ends of reform, and that shared understandings of policy innovation, alongside informational infrastructures for the systemic propagation and codification of useful practices, provide a framework for managing change in complex environments and under conditions of uncertainty in which ‘what works’ is not knowable in advance. The article situates China’s use of experimentation and innovation in management of health system reform in relation to recent literature which applies complex systems thinking to global health, and concludes that there are lessons to be learnt from China’s approaches to managing complexity in development of health systems for the benefit of the poor.

Background
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.

Despite a number of important global public health successes, for many health behaviours there is a continued lack of interventions that have been sufficiently scaled up to achieve system-wide integration. This has limited sustainable and equitable population health improvement. Systems change plays a major role in the relation between implementation processes and at-scale institutionalisation of public health interventions. However, in research, systems approaches remain underutilised in scaling up. Public health scale-up models have typically centred on intervention replication through linear expansion. In this paper, we discuss current conceptualisations and approaches used when scaling up in public health, and propose a new perspective on scaling that shifts attention away from the intervention to focus instead on achieving the desired population-level health outcomes. In our view, ‘scaling up’ exists on a continuum. At one end, effective scaling can involve a linear, intervention-orientated expansive approach that prioritises the spread of evidence-based interventions into existing systems in order to drive expansion in the application of that intervention. At the other end, we contend that scale-up can sit within a complex systems paradigm in which interventions are conceptualised as events in systems. In this case, implementation and scale-up activities should focus on generating changes within the system itself to achieve the desired outcome. This we refer to as ‘systems-orientated scale-up’ to achieving population health improvement, which can complement traditional approaches in relevant situations. We argue that for some health behaviours, our proposed approach towards scaling up could enhance intervention implementation, sustainability and population health impact.

Background

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.

Many global health programs in low- and middle-income countries focus on supporting scale-up to accelerate health gains. Scale-up efforts aim to expand and institutionalize proven health interventions so that they become a part of routine practice within national health systems and available to everyone who needs them. At the same time as greater attention is being paid to taking interventions to scale, practitioners, donors, and researchers in global health are changing their thinking about how national health systems work. Replacing the traditional view of Ministries of health as unified institutions that can be molded into new forms, national health systems are increasingly being recognized as complex adaptive systems (CASs) with diverse components and actors that interact in multiple ways with each other and with the external environment. When interventions are scaled up within such systems, there are multiple interactions with these various components and actors in complex ways, making outcomes unpredictable. There are potential tensions between the goal of scaling up specific, well-defined health interventions in every hospital, clinic, and community across a country and the complex reality of how health systems deliver services. Although scale-up efforts frequently attempt to make the desired intervention as simple as possible to implement, even simple interventions require replacing an old behavior with a new one which is an inherently complex endeavor. The variable results of efforts to increase and maintain the use of new health technologies and practices suggest that we have more to learn about how to achieve scale. Researchers have drawn on practical experience and complexity science to offer insights into how scale-up efforts can best take account of the complex nature of health systems (Paina & Peters 2012; Ramalingam 2013). However, there has been relatively little empirical evidence on how CASs positively and negatively affect scale-up processes and outcomes and, more importantly, how scale-up efforts can harness aspects of CASs to produce desired changes.

With prevailing concerns about the generalizability of evidence-based treatments (EBTs) in real-world practice settings, there has been increased attention to the potential of cultural adaptations of treatments to ensure fit with diverse consumer populations. However, it could also be argued that there has been insufficient dissemination and evaluation of our existing EBTs with minority populations to warrant and guide adaptation efforts. This article discusses a framework (a) for identifying instances where cultural adaptation of EBTs may be most indicated, and (b) for using research to direct the development of treatment adaptations to ensure community engagement and the contextual relevance of treatment content. Ongoing work in the area of parent training is highlighted to illustrate key issues and recommendations. Key words: cultural adaptation, evidence-based treatments, minority children and families, parent training

As an emerging approach to research, complexity science is a study of a system. It is not a single theory, but a collection of theories and conceptual tools from an array of disciplines (Benham-Hutchins & Clancy, 2010; Paley & Gail, 2011). For example, complexity science has been taken up in both natural (i.e. mathematics) and social sciences (ecology), and has become increasingly popular in health care literature. Complexity science is concerned with complex systems and problems that are are dynamic, unpredictable and multi-dimensional, consisting of a collection of interconnected relationships and parts. Unlike traditional “cause and effect” or linear thinking, complexity science is characterized by nonlinearity. According to Miles (2009), complex systems and problems require more than simplistic linear thinking. With a complexity science perspective, there is an appreciation of the complex, dynamic and interconnected relationships occurring within a complex system or problem. Considering the public and population health issues of obesity or chronic disease, there are a multitude of factors and relationships that contribute to the problem. Therefore, a public and population health intervention requires an approach that can account for the complexity of the issue. In other words, public health professionals can be more effective if they understand the complex relationships that are occurring, rather than reducing problems to their smaller parts (Miles, 2009).

This synthesis paper suggests how problem-driven approaches supported by adaptive programme management can be implemented at scale in relation to donor programming aimed at institutional reform and improving state capability. It suggests changes to the way standard programme models are applied in practice by DFID and other donors, in light of new thinking about how donors can best support the complex issue of institutional reform, drawing on LASER\\\'s experience on the ground. Two key adjustments to current donor programming approaches are suggested: (1) Put programme function before form: Take time to identify and interrogate institutional problems that local people care about before determining what type of scaled-up donor programming is appropriate – in particular what kind of delivery mechanism and what level of funding. (2) Scope and design the form of donor programming by discovery and doing: Systems thinking suggests that complex institutional problems are best understood, and solutions identified by a process of discovery, rather than primarily by analysis. Scoping/design before a major donor programme ‘crystallises’ and programme form and budget are set, should focus on learning by doing – facilitating local people to iterate around problems to deconstruct them and identify solutions that work for them, and which scaled up donor programming may be able to support. This approach is not appropriate for all donor programming, but it is suggested that there should be space within donor programme portfolios for this approach to be applied to complex institutional reform issues, and that some programming should therefore incorporate: a much longer ‘scoping/design’ process (typically 1-2 years), before programme ‘crystallisation’ i.e. before a scaled up programme delivery mode and budget are determined; a new conceptualisation of scoping/design - involving ‘getting stuck in’ and working with local people on problems they care about without putting money on the table. This requires soft rather than primarily analytical skills; and a narrow entry point to scoping/design through a problem that local people who are able to bring about change wish to engage with. This conceptualisation of scoping/design as an extended process of discovery and learning by doing is likely to be undertaken by contractors with the appropriate soft skills, as well as technical ability, but before the form of scaledup programming has been determined. The paper suggests a range of contracting models to enable this, including: the development of flexible country-level or centrally managed flexible programmes mandated to provide responsive technical assistance for complex institutional reform issues and scope/design by doing in response to emerging opportunities. Such programmes could be sector specific e.g. for the justice sector or for institutional reform issues across the board; or the use of existing framework arrangements. This type of flexible programming for scoping/design, which provides relatively low-key technical assistance, and does not put large-scale funding on the table up front, could lead to the development of more conventional scaledup programmes, once time has been taken to interrogate and iterate around problems, and determine the most appropriate form and funding level for new programming. Once a new programme has ‘crystallised’ and its delivery model and funding levels determined, the appropriate degree of flexibility can be achieved through adaptive programme management and ongoing re-design through learning and adapting, consistent with DFID Smart Rules and requirements for programme management.

CLA Activities and Processes These are some of the types of activities and processes that Missions may consider including in their CLA Plans, as appropriate: Strategic Collaboration • Coordinating site visits among technical teams to encourage collaboration • Facilitating implementing partners’ efforts to collaborate and share information with each other through joint work planning sessions or other means Learning • Developing learning agendas or questions around critical knowledge gaps at the Development Objective, project, or activity level • Identifying trends or changes in the context that could impact the portfolio and processes for tracking and responding to them • Participate in knowledge sharing forums, such as communities of practice and learning networks Reflection to Inform Adaptation • Planning for facilitated reflection sessions with local stakeholders to regularly gather information on context changes • Instituting stocktaking and other reflection opportunities to consider new learning, shifting priorities, and necessary adaptations

Development actors increasingly agree that a confluence of new challenges and greater complexity require aid agencies to be more agile. We need to be able to adapt in a timely and intentional way, by better understanding, and responding to, contextual dynamics. How, then, can we set up our organizations, country offices and programs to be better able to adapt? This paper pulls out practical tips and short examples for what we have found to be the most important elements of adaptive management at Mercy Corps: Organizational culture provides the cues, expectations and incentives to prioritize learning and adaptation. This section provides suggestions for leadership, teamwork, physical cues and the importance of reinforcing culture through formal mechanisms. People and skills: Adaptive management depends upon a respected, empowered and accountable team, equipped with the skills of critical thinking, analysis and creativity who are expected to gather and use data and information in their work. This section looks at team composition, recruitment, skills building and coaching, and accountability. Tools and systems: A foundational culture of investigation, debate and agility needs to be supported and reinforced by a broad set of tools (both technical and managerial), processes (such as recruitment) and systems (such as finance, procurement and M&E). This section looks at tools and systems for planning and monitoring, regular analysis, providing space for reflection, piloting approaches and internal systems, norms and policies. Enabling environment: To do adaptive management, and work on the changes needed in the first three components often goes beyond the vision of an agency. The ability to be lean and nimble requires buy‐in and flexibility from the broader enabling environment, such as donors and host governments. This section talks about how donors’ systems and expectations can support adaptation at initial program design and implementation stages.

Abstract Action research (AR) can be an effective form of ‘on the job’ training. However, it is critical that AR cycles can be appropriately recorded in order to contribute to reflection and learning. One form of recording is for coresearchers to keep a diary. We found no previous literature describing the use of diaries in AR in sub-Saharan Africa. We therefore use this paper to reflect on how diaries were used by district health management teams in the PERFORM project. We share five lessons from our experience. First, it is important to foster ownership of the diary by the people who are responsible for filling it in. Second, the purpose of keeping a diary needs to be clear and shared between researchers and practitioners from the very beginning. Third, diaries should be allowed to evolve. Fourth, it is a challenge for busy practitioners to record the reflection and learning processes that they go through. Last, diaries on their own are not sufficient to capture reflection and learning. In conclusion, there is no best way for practitioners to keep a diary; rather the focus should be on ensuring that an AR recording process (whether diary or otherwise) is locally owned and complements the specific practice setting.

Keywords Diaries, action research, district health management teams, Ghana, Tanzania, Uganda

Adaptive management is an approach to tackling international development challenges that are complex. The starting point is an assumption of uncertainty about what will work to address the challenge. It is then characterised by a flexible approach involving testing, monitoring, getting feedback and – crucially – making course-corrections if necessary. Adaptation is often defined as an alternative to approaches that emphasise adherence to detailed plans to solve development problems in a more linear, mechanistic way. In practice, the management of most interventions falls somewhere along a spectrum between linear and adaptive. Adaptive management is best understood as a broad approach, rather than as a specific method or set of tools. This introductory paper is intended for managers and leaders in civil society organisations and funders, who are not already immersed in the issue. It provides insight into what adaptive management is, when and why it may be appropriate, and what may be required for organisations to adopt adaptive approaches. Working adaptively may not be appropriate in all circumstances. There are relatively simple problems and simple contexts in which more traditional, linear programming approaches are valid. However, it is increasingly recognised that many key development challenges have complex features – from addressing climate change to institution-building to migration to addressing inequality. And the contexts in which those challenges need to be addressed are often also complex. Even many “simple” interventions (such as vaccinating children) take on complex dimensions when they need to be implemented in difficult environments such as fragile and conflict-affected states. CSOs and funders will need to work in more adaptive ways than they currently do to respond appropriately and effectively. There are many existing tools and techniques that can be used for adaptive management (participatory appraisal, political economy analysis, feedback mechanisms, etc.). However, to increase adaptive management practice, arguably a greater focus is needed on creating the right institutional and funding conditions to enable and facilitate it, including more widespread acceptance of uncertainty and risk in programming. This may require quite profound changes for some organisations, meaning that the challenge of increasing the use of adaptive management should not be underestimated.

Learning-by-doing, SOCIAL ACCOUNTABILITY, feedback loops, learning loops, World Bank, M&E, Monitoring and Evaluation

Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services. Complex adaptive systems, health systems, scaling up, health planning Topic: developing countriesfeedbackhealth serviceslens, crystallinelens (device)world health

Perceptions matter. And COVID-19 reminds adaptive managers that frontline perceptions may matter the most.

This working paper compares six of the most prominent adaptive approaches to emerge over the past two decades. Three come from the world of innovation, largely in the private sector (agile, lean startup and human-centred design), and three from the global development sector (thinking and working politically, forms of adaptive management and problem-driven iterative adaptation). While all of these approaches are valuable when used in the right context, practitioners may be perplexed by the multiplicity of methods and jargon. This paper aims to address some of this confusion by mapping where these approaches have come from and showing how they can be applied across the adaptive programme cycle. Armed with this knowledge, practitioners might experiment with different combinations and sequences of adaptive approaches according to the kind of problem and context faced. In turn, this may help us move beyond a siloed view of approaches linked to innovation, adaptive management or more politically smart ways of working.

The science of complex adaptive systems provides important concepts and tools for responding to the challenges of health care in the 21st century Clinical practice, organisation, information management, research, education, and professional development are interdependent and built around multiple self adjusting and interacting systems In complex systems, unpredictability and paradox are ever present, and some things will remain unknowable New conceptual frameworks that incorporate a dynamic, emergent, creative, and intuitive view of the world must replace traditional “reduce and resolve” approaches to clinical care and service organisation

Abstract Introduction Scaling-up is essential to ensure universal access of effective health interventions. Scaling-up is a complex process, which occurs across diverse systems and contexts with no one-size-fits-all approach. To date, little attention has been paid to the process of scaling-up in how to make adaptations for local fit. The aim of this research is to develop theory on what actions can be used to make adaptations to health interventions for local fit when scaling-up across diverse contexts that will have practical application for implementers involved in scaling-up. Methods and analysis Given the complexity of this subject, a realist review methodology was selected. Specifically, realist review emphasises an iterative, non-linear process, whereby the review is refined as it progresses. The identification of how the context may activate mechanisms to achieve outcomes is used to generate theories on what works for whom in what circumstances. This protocol will describe the first completed stage of development of an initial programme theory framework, which identified potential actions, contexts, mechanisms and outcomes that could be used to make adaptations when scaling-up. It will then outline the methods for future stages of the review which will focus on identifying case examples of scale-up and adaptation in practice. This realist review consists of six stages: (i) clarifying scope and development of a theoretical framework, (ii) developing a search strategy, (iii) selection and appraisal, (iv) data extraction, (v) data synthesis and analysis and (vi) further theory refinement with stakeholders.

The tools of complex systems research, which emerged from scientific research, are already used and valued by the private and public sectors to better analyse and navigate a range of wicked problems across many disciplines. International development is starting to catch on, with a number of initiatives and projects in this area. Many development partner tools and business processes deal with static, simple or linear problems. There is considerable demand for new methods and principles that can help development partners better navigate the complex, dynamic realities they face on a day-to-day basis. What we did This project looked at the appetite for these new methods in DFID and tested a number of tools and principles in four small-scale pilots: looking at system dynamics in trade; adaptive management and complexity-informed theories of change in private sector development; network analysis in girls’ empowerment; and systems thinking in programme management. What we found There is a significant appetite for improved tools and principles that can help DFID better deliver on its programming. The pilots contributed to improved analysis and understanding of problems, provided a valuable means by which to engage with the wicked nature of challenges, and created sound insights about the kinds of interventions that might be appropriate. The pilots generated tangible findings that were directly utilised in corporate and programmatic decisions. They played a significant role in the design of two large programmes, and provided the evidence base for a root and branch review of DFID processes. The findings were not unanimously positive, however: the pilot recommendations were not always tailored to DFID’s organisational realities, and needed some reworking. Moreover, some of the methods did not fit easily within DFID processes and required some adaptation. The terminology and visualisations were in some places hard for DFID staff to understand. FROM BEST PRACTICE TO BEST FIT v  improve their understanding of wicked problems in different areas of development work  trial and adapt new tools to improve analysis and programming in the face of these problems  ensure their internal systems, processes, skills and capacities can support these improved analytical and programming approaches  build linkages with complexity specialists in different sectors to support all of the above. Complex systems specialists should:  work at adapting tools from other sectors to development work  simplify terminology and make methods more accessible  build the evidence of benefits and costs of applying complex systems methods in different contexts

Global health as a discipline is at a moment of tremendous achievements and general optimism, but faces enduring questions, notably about the sustainability of its endeavours. The field of global health defines itself through enumerated goals, targets, and indicators to track progress of complex changes. With this comes a broad panoply of objective-driven strategies resting on assumed control over chains of cause and effect. We present areas where emergence and self-organization play an important role in determining the sustainability of positive outcomes at scale and behaviours of both the population and its service providers. The role of self-organization and emergence seem under-appreciated by the field and we consider three reasons for a possible “blind spot” of global health decision makers and influencers: (1) the culture of command and control inherent to central planning, (2) the structural limitations of large complex institutional edifices in processing information (variety), and (3) epistemological/cognitive constraints. More pro-active allowance for the conditions of positive self-organization and emergence may be required to avoid unintended and negative long-term consequences of global strategies, in spite of best intentions. Observational, analytical and computational multi-disciplinary studies are needed to bring clarity to these questions, and to inform a parallel process of dialogue, provocation, and learning to evolve the institutional culture of global health at both national and international levels.

Adaptive management (AM) remains a commonly cited, yet frequently misunderstood, management approach. The aim of AM is to improve environmental management through ‘learning by doing’ and understand the impact of incomplete knowledge, but AM more commonly consists of ad hoc changes in managing environmental resources in the absence of adequate planning and monitoring. Here, we trace and review the development of AM, the central roles of consultation, collaboration and of monitoring, and of quantitative models and simulations. We identify a series of formalized, structured steps included in one AM cycle and review how current AM programs build upon such cycles. We conclude that the best AM outcomes require rigorous and formalized approaches to planning, collaboration, modelling and evaluation. Finally, simulating potential outcomes of an AM cycle in the presence of existing uncertainty can help to identify management strategies that are most likely to succeed in relation to clearly articulated goals. Key words adaptive environmental assessment and management, modelling, uncertainty

The last decade has seen a growing interest in scaling up innovations to realise wider benefits from development investments. While numerous proven technologies, products and models have been successfully piloted, scaling them up through expansion, adoption and replication has proved challenging, particularly in poor regions of the world. The low uptake of innovations is partially attributed to the design of technologies, in a manner that is not compatible with local farming practices. At the same time, proven innovations fail to generate large impacts at scale because implementing actors have not sufficiently understood or effectively engaged with the scaling process. This article shares lessons from the Canadian International Food Security Research Fund (CIFSRF) that supported applied research to develop, test and scale up promising food and nutrition security innovations. Key lessons include ensuring that innovations are embedded within local socio-ecological systems; engaging end users throughout the research process and enabling participatory decision-making; and considering the investment returns of innovations for end-users. KEYWORDS: Aid – Capacity DevelopmentCivil society – Participation, PartnershipEnvironment (built and natural) – Food security

Policies to promote public health and welfare often fail or worsen the problems they are intended to solve. Evidence-based learning should prevent such policy resistance, but learning in complex systems is often weak and slow. Complexity hinders our ability to discover the delayed and distal impacts of interventions, generating unintended “side effects.” Yet learning often fails even when strong evidence is available: common mental models lead to erroneous but self-confirming inferences, allowing harmful beliefs and behaviors to persist and undermining implementation of beneficial policies. Here I show how systems thinking and simulation modeling can help expand the boundaries of our mental models, enhance our ability to generate and learn from evidence, and catalyze effective change in public health and beyond. The United States spends more on health care than any other nation (15.3% of gross domestic product [GDP] in 2003, up from 5.1% in 1960).1,2 Yet the return on this huge investment is discouraging: the United States ranks 33rd in life expectancy and 35th in infant mortality.2 More than 40 million have no health insurance. Minorities and the poor have significantly lower life expectancy than others.3 Nearly two thirds of US adults are overweight, and almost one third are obese.4 Diabetes and cardiovascular disease are rampant. The number of unhealthy days Americans experience is growing.5 Preventable medical errors kill tens of thousands each year.6 From Staphylococcus aureus to malaria to HIV, morbidity and mortality from drug-resistant pathogens grows.7 Most disturbing, many of these afflictions are the unintended consequences of the extraordinary prosperity and technical progress that enabled us to treat disease and decrease daily toil so successfully over the past century. Health care is not unique. Thoughtful leaders throughout society increasingly suspect that the policies we implement to address difficult challenges have not only failed to solve the persistent problems we face, but are in fact causing them. All too often, well-intentioned programs create unanticipated “side effects.” The result is policy resistance, the tendency for interventions to be defeated by the system’s response to the intervention itself. From overuse of antibiotics that spread resistant pathogens, to the obesity caused by the sedentary lifestyles and cheap calories our prosperity affords, our best efforts to solve problems often make them worse (box next page).

Background
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.

Continuous Learning & Improvement Relationships & Networks Openness Decision-Making Institutional Memory Knowledge Management CLA in Implementing Mechanisms Resources Mission Internal Collaboration External Collaboration Pause & Reflect Adaptive Management Technical Evidence Base Theories of Change Scenario Planning M&E for Learning

This Discussion Note complements ADS 201.3.1.2 Program Cycle Principles by elaborating on Principle 2: Manage Adaptively through Continuous Learning. This Discussion Note is intended for USAID staff interested in learning about recent and promising practices in adaptive management across the Program Cycle. USAID’s work takes place in environments that are often unstable and in transition. Even in more stable contexts, circumstances evolve and may affect programming in unpredictable ways. For its programs to be effective, USAID must be able to adapt in response to changes and new information. The ability to adapt requires an environment that promotes intentional learning and flexible project and activity design, minimizes the obstacles to modifying programming and creates incentives for managing adaptively. Adaptive management is defined in ADS 201.6 as “an intentional approach to making decisions and adjustments in response to new information and changes in context.” Adaptive management is not about changing goals during implementation, it is about changing the path being used to achieve the goals in response to changes. Like other donors and development organizations (see, for example, the following initiatives: Doing Development Differently, Problem-Driven Iterative Adaptation, Thinking and Working Politically, and The World Bank’s Global Delivery Initiative), USAID is increasingly recognizing the importance of adaptability for its work to be effective. ADS 201 now integrates adaptive management approaches throughout the Program Cycle. “Manage adaptively through continuous learning” is one of the four core principles that serve as the foundation for Program Cycle implementation. This Discussion Note is organized around the phases of the Program Cycle (strategy, project, and activity design and implementation; monitoring and evaluation; and learning and adapting); While the adaptive management approaches described here are examples of initial entry points associated with a specific phase of the Program Cycle, many of these approaches lead to adjustment in other areas. The note concludes with sections on enabling conditions and a description of the skills and attributes of adaptive managers.

Performance monitoring is intended to “reveal whether implementation is on track and whether expected results are being achieved (ADS 201.3.5.5.)” Complexity-aware monitoring complements performance monitoring for aspects of strategies, project and activities where cause-effect relationships are uncertain and agreement on problems and solutions is low. When USAID staff identify components of strategies, projects, and activities that meet these criteria, they may consider using complementary monitoring approaches that are complexity-aware in order to address performance monitoring’s three blind spots (unintended outcomes, alternative causes and feedback loops), synchronize with the pace of change, and consider key systems concepts, such as interrelationships, perspectives, and boundaries. Complexity-aware monitoring can be used in conjunction with performance and context monitoring keeping in mind the distinctive strengths of each.

Collaborating, Learning, and Adapting (CLA) is a set of practices that help us improve our development effectiveness. Learning has always been part of USAID’s work, and most USAID missions and implementing partners are already practicing CLA in some way. Our aim now is to make CLA more systematic and intentional throughout the Program Cycle, and to dedicate the resources necessary to make it happen. According to USAID’s Program Cycle guidance (ADS 201.3.7), “Strategic collaboration, continuous learning, and adaptive management link together all components of the Program Cycle.” Integrating CLA into our work helps to ensure that our programs are coordinated with others, grounded in a strong evidence base, and iteratively adapted to remain relevant throughout implementation. The systematic application of CLA approaches, led by people who have the knowledge and resources to carry them out, enables USAID to be an effective learning organization and thereby a more effective development organization. In the simplest terms, integrating collaborating, learning, and adapting throughout the Program Cycle can help development practitioners address the above challenges by thinking through: Collaborating: Are we collaborating with the right partners at the right time to promote synergy over stove-piping? Learning: Are we asking the most important questions and finding answers that are relevant to decision making? Adapting: Are we using the information that we gather through collaboration and learning activities to make better decisions and make adjustments as necessary? Enabling Conditions: Are we working in an organizational environment that supports our collaborating, learning, and adapting efforts?

Adaptive programming suggests, at a minimum, that development actors react and respond to changes in the political and socio-economic operating environment. It emphasises learning and the development practitioner is encouraged to adjust their actions to find workable solutions to problems that they may face. Being prepared to react to change may seem like common sense – and indeed it is. However much development thinking and practice remains stuck in a linear planning model which discourages learning and adaptation, in part because projects are seen as ‘closed, controllable and unchanging systems’ (Mosse, 1998: 5). This paper critically engages with this problem and makes clear why and how learning needs to be at the centre of adaptive development programming. It begins by clarifying why and what kind of learning matters for adaptive programming. The paper then turns its focus to how strategies and approaches applied throughout a programme’s conception, design, management and M&E can enable it to continually learn and adapt. Global Monitoring, evaluation and learning Fragile states Aid

Background
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.

Summary
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.

Recommendations – How could Adaptive Management be encouraged and addressed by Donors and Host Governments? Encourage implementing partners to embrace AM and the ways and means to tackle complexity. Strongly support the host Government’s drive for more information and data on their current situation and development needs, not just at the project level but improvements to national statistics, and poverty data Share and encourage open access policies; free and open access to publicly-funded research offers significant social and economic benefits. Development bodies must not be allowed to hoard data Encourage adaptive management with innovative funding mechanisms, encouragement for innovative research, and development of new technology solutions to managing aid and improving VFM. Support local universities to develop their capacity, encourage partnerships, north-south, south-south Ensure all programme designs and implementation plans draw on the perspectives of local partners and those with whom they work. Gateways in the programme and project approval process will need to demand that provision is made for systematic MEL. In situations where Development Trust Funds operate ensure that all proposed projects incorporate a clear statement on MEL and how the programme/project will provide a steady stream of information that is used to understand the context and programme performance, and how the information will be stored and made accessible. In short, a closer focus on accountability for learning Establish more joint programmes for both DPs and other partners to learn about Adaptive Management and PDIA type approaches; adopt a joint commitment to collaborative learning. In complex emergencies where humanitarian and development action co-exists, demand joint approaches to understanding and responding.

This course will help you answer the following questions:

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?

The Global Fund to Fight AIDS, Tuberculosis and Malaria was established in 2002 to provide large-scale financing to middle- and low-income countries to intensify the fight against the 3 diseases. Its model has enabled strengthening of local health leadership to improve governance of HIV programs in 5 ways. First, the Global Fund has encouraged development of local capacity to generate technically sound proposals reflecting country needs and priorities. Second, through dual-track financing-where countries are encouraged to nominate at least one government and one nongovernment principal recipient to lead program implementation-the Global Fund has enabled civil society and other nongovernmental organizations to play a critical role in the design, implementation, and oversight of HIV programs. Third, investments to strengthen community systems have enabled greater involvement of community leaders in effective mobilization of demand and scale-up for services to reach vulnerable groups. Fourth, capacity building outside the state sector has improved community participation in governance of public health. Finally, an emphasis on inclusiveness and diversity in planning, implementation, and oversight has broadly enhanced country coordination capacity. Strengthening local leadership capacity and governance are critical to building efficient and equitable health systems to deliver universal coverage of HIV services.

Purpose:
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.

Background
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.

Key messages To aid in the transparency and predictability of transition processes, we need:
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.

Four lessons from Togo on scaling health care innovation through the public sector. On the night before Integrate Health’s first Community Health Worker training in 2015, we got a startling call: “Please take the Ministry of Health logo off the training materials.” Integrate Health had worked with the Ministry of Health’s District Health Director, from day one, to design the program. But she had gotten cold feet. Gbeleou went to her office the next morning, and emerged after an hour, shaking his head. We had secured permission to proceed with the training and launch the program, with only the NGO logo on the training materials. The program that Integrate Health and the Ministry of Health were piloting together, the Integrated Primary Care Program, had acquired all of the necessary approvals and was even part of a joint study. But it was also different—Community Health Workers were being paid to work full-time, unlike the country\'s volunteer model—and different can be risky. Since that initial rocky start in 2015, Integrate Health has made significant progress in strengthening our partnership with the Ministry of Health. In fact, Gbeleou and Dr. Sibabe Agoro, Regional Health Director for the Ministry of Health in Togo, had just returned from obtaining their UK visas in March of this year when they learned that the Skoll World Forum had been canceled due to COVID-19. Gbeleou and Dr. Agoro had planned to travel to Oxford to participate in a panel discussion on government and NGO partnership at scale. But as the novel coronavirus grew to a pandemic, the critical need for effective NGO and government collaboration rapidly accelerated. 1. Center the voice of government. 2. Implement within existing government delivery and data systems. 3. Build relationships with government partners at all levels. 4. Progressively transfer real ownership to government partners.

Aid allocations by donor countries to sexual and reproductive health and rights and the values that underlie that aid are a timely and important topic. In general, data about such funding are weak and the field would benefit significantly from better and more comprehensive data on what the funds are earmarked for and how they are used. In the absence of such data, it is extremely difficult to address the issue objectively. This paper is a response to the paper by Sara Seims on improving the impact of sexual and reproductive health development assistance from the seven like-minded European donors.1 It offers a different perspective on several of the key issues she raises.

Monitoring and Evaluation. The first step is planning. Countries must start with a clear development vision, but they also need to elaborate a detailed roadmap for realising it. In Ethiopia, our vision is to become a middle-income country over the next 10–15 years, and our government has clearly articulated strategies for how to get there. For country ownership to be realised, development partners must allow countries the space to identify their own needs and priorities, and develop their own plans as they see fit. But countries should also be open to ideas and seek to tailor proven practices to their particular circumstances. Once a well-considered national plan is in place, however, partners need to support that plan if country ownership is to thrive. We remained open to ideas throughout the planning process. We invited partners\' contributions and benchmarked best practices from other countries. This is the most decisive step towards real ownership. The second step is resourcing the plan. Here too, countries must take the lead. And because resources are limited, careful prioritisation is crucial. In crafting our health plan, we defined two alternative versions. If resource constraints mean that we cannot implement our broader and more ambitious plan, we go with our contingency plan, which focuses on the most pressing priorities. Even more important is the way in which resources are channelled. Flexible and predictable funding fosters accountability and ownership by allowing countries greater leverage in responsibly managing resources. Direct budget support is the ideal mechanism, in view of the enhanced flexibility and control it affords countries. In cases where our partners\' chosen mechanism is not budgetary support, we have negotiated ways in which the funding can be used to benefit the whole health system. We have even used vertically raised funds—ie, those earmarked for disease-specific services—to strengthen our health system. For example, about 25–30% of HIV/AIDS grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria and 15% of resources from the US President\'s Emergency Plan for AIDS Relief have been used to build system capacities in many areas, including an information system for health management, a supply-chain management system, and major improvements in human resources. The third step is implementation, in which countries must also be fully engaged. Some have argued that countries lack the capacity to implement. If so, the most efficient and sustainable solution is for partners to strengthen existing capacities within the country rather than replacing them with parallel structures. If existing national systems and procedures are inadequate, partners should work with countries to fix them.

KEY POINTS
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.

Background
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.

Increasingly, governments and international development actors recognize the importance and challenges of achieving impact at scale, but there remains a glaring gap between stated intentions and actual practices. A movement is emerging to professionalize discussions about scale and scaling and to place these issues in the center of the development conversation; and the Global Community of Practice on Scaling Development Outcomes (CoP) has been actively engaged at the crossroads of this movement. Active since 2015, the CoP’s 2000+ members – representing more than 400 official donors, foundations, governments, academic institutions, think tanks, NGOs, private companies and social enterprises – are drawn from the global north and the global south. The CoP’s mission is to use its multi-sectoral composition, diversity, independence and convening capacity to provide direct support to its members and to professionalize the practice of scaling in members’ organizations and more broadly.

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.

A systematic approach to scale-up was applied to expand an integrated package of family planning and primary healthcare services from the Democratic Republic of the Congo\\\\\\\'s South Kivu province to health zones in Lomami, Lualaba, and Kasai Central provinces. This approach was based on recommendations from the ExpandNet/WHO guide Beginning with the end in mind. The approach emphasized application of three recommendations: engaging government stakeholders, ensuring the relevance of the intervention, and tailoring the innovation to the setting. This approach led to successful scale-up of community-based family planning, increasing access to and uptake of contraception and demonstrating potential for sustainability; 231,566 new acceptors were recruited and 149,826 couple-years of protection were generated. The systematic scale-up approach led to integration of community-based family planning indicators in the national health information system and transferred ownership of the interventions to the government, creating and strengthening government platforms with potential to sustain the interventions. Keywords: DRC; adaptation; communities; family planning; integration; systematic scale-up.

In the world of global aid and development, country ownership has become one of the most debated issues. But what does country ownership mean in practical terms to donors, development partners, civil society, and country governments? If the goal is to put each country into the driver's seat, how can we get there? For nearly five years, the Ministerial Leadership Initiative for Global Health - MLI - has forged new pathways for advancing this critical development issue, working with five countries in Africa and Asia. What emerged is a distinctive MLI Model to advance country ownership.

Social accountability approaches have been gaining popularity and attention in the international development community as both donors and governments have responded to demands from citizens and civil society organizations to establish more transparent, accountable, and responsive public service processes. At their core, these social accountability approaches provide ways for citizens to hold their governments accountable for the deli very and provision of quality public services by engaging directly with policy makers, civil servants, and service providers.

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.

Introduction:
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.

If you consider global health as something you do to help those ‘vulnerable others’, then you might find the lessons in this piece burdensome. The fact is global health is not charity, and you are its first client, the abiding lesson from the COVID-19 pandemic. Understanding this will ensure you practice global health with the most powerful tool you have–empathy. If your approach to supporting countries and communities in need is one that you would find unacceptable if circumstances were reversed, stop and recalibrate. Donor investment in global health, unfortunately, is often driven by geopolitics, as powerful countries and entities try to construct or retain spheres of influence. At times, the geopolitical objectives may conflict with your conscience. Speak up when you can, importantly however, do your best to behave conscientiously, as it is the collective, sustained behaviors of individuals that shape institutional culture.

When it comes to supporting innovations at large scale, governments play a central role. But nonstate actors, such as researchers or project implementers, are also essential. Often, they’re the ones who design, pilot, and promote the innovations—hoping one day to hand the initiative over to the government for collaborative, long-term adoption. As evidence: In the Center for Universal Education’s global catalog of nearly 3,000 education innovations, two-thirds of them were started in the nonprofit sector, while only 12 percent originated in government. This means that nonstate education actors must become adept at presenting, proving, and pitching innovations to government. They need to learn how government decisionmakers identify and adopt innovations for scale, and the more the implementers and researchers know about the decisionmaking process, the more effective they can be.

Many contemporary practitioners and researchers tasked with bringing proven education innovations to scale around the world know that scaling is less a technical activity, but a mindset as much as an implementation process. As an adaptive mindset, scaling shares myriad characteristics with its close cousin: innovation. Both are complex and demand creative thinking, their outcomes are never fully predictable, and both require flexibility and engagement with the “what-ifs?” of life. And, yet, to be supported at scale by government, most education innovations first must be adopted by public-sector decisionmakers—a group that lives within a decidedly bureaucratic culture. The contradiction between the government mechanics of adopting innovations and the culture of implementing them becomes a central barrier to education innovations being adopted at scale.

The World Bank and the government of Cameroon launched a performance-based financing (PBF) program in Cameroon in 2011. To ensure its rapid implementation, the performance purchasing role was sub-contracted to a consultancy firm and a nongovernmental organization, both international. However, since the early stage, it was agreed upon that this role would later be transferred to a national entity. This explanatory case study aims at analyzing the process of this transfer using Dolowitz and Marsh’s framework. We performed a document review and interviews with various stakeholders (n D 33) and then conducted thematic analysis of interview recordings. Sustainability, ownership, and integration of the PBF intervention into the health system emerged as the main reasons for the transfer. The different aspects of transfer from international entities to a national body consisted of (1) the decision-making power, (2) the “soft” elements (e.g., ideas, expertise), and (3) the “hard” elements (e.g., computers, vehicles). Factors facilitating the transfer included the fact that it was planned from the start and the modification of the legal status of the national organization that became responsible for strategic purchasing. Other factors hindered the transfer, such as the lack of a legal act clarifying the conditions of the transfer and the lack of post-transition support agreements. The Cameroonian experience suggests that key components of a successful transfer of PBF functions from international to national organizations may include clear guidelines, co-ownership and planning of the transition by all parties, and post-transition support to new actors.

Background
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.

Background
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.

Sustaining impact through government is a critical pathway to scale for many social impact organizations. But what do government partners advise on how to do so successfully? Governments bring networks and infrastructure to reach more people, authority over public spending and an understanding of their population’s needs and values. As such, many social impact organizations believe the government is best placed to scale and sustain the impact of solutions over the long-term, particularly in low-resource settings. However, effectively and sustainably transitioning solution ownership to government is complex, particularly when navigating the challenges of shifting resource-constrained settings. There is recognition that to do so successfully requires strong partnership between all the stakeholders involved – government, social impact organizations and funders – but these different organisations do not always have the same priorities, and government perspectives can be diluted or lost. Through Spring Impact’s work with VillageReach – an international non-profit that transforms health care delivery to reach everyone – we have been developing a Learning Network to bolster knowledge around how to successfully embed solutions into government systems. Recognising that government voices are insufficiently heard, we have a particular goal to ensure government input into building this knowledge. We recently hosted a webinar – in partnership with VillageReach and Devex – which shared insights from voices across governments in Cameroon, Ethiopia and Uganda, on how to partner effectively with government to scale social impact.

The Government of Ethiopia is seen as a owner of its national programs and policies and thus also as a strong coordinator of the foreign aid it receives. This is also the case in the health sector in Ethiopia, where the Ministry of Health have shown leadership in the last two decades. National health plans have been clear-cut and had ambitious objectives, to which the international donor community has adhered. The government-led coordination structures and joint health financing arrangements have been instrumental for improved donor coordination and aid effectiveness in the sector. This has led to impressive results, looking at the poor state of health that the government inherited from former regimes. However, the sector has at once been heavily dependent on foreign sources and characterized by high aid fragmentation. In this paper, we describe the health plans and health financing between 1990 and 2015. We also look at health leadership, donor coordination, and the results of investments in health. KEYWORDS: Health aid donor coordination aid effectiveness Ethiopia

Few people doubt that innovations from outside the public sector can help governments address myriad social problems. What is much less clear is the pathway for ensuring that promising innovations are sustained at scale. As Africa Regional Advisor for Health Innovation at WHO, Dr. Moredreck Chibi is helping light the innovation path for the 47 member states in the Africa region.

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.

The ‘Journey to Scale with Government’ tool provides governments, social impact organisations and funders with a foundation for stronger collaboration in developing solutions that can be sustained at scale. While there are many approaches to achieving government ownership and leadership, this tool focuses on the pathway in which government adopts* a solution, and integrates it into government systems. This tool has three sections: Setting Out, The Mindset Shift, The Journey.

The US President’s Emergency Plan for AIDS Relief (PEPFAR) has shifted from an emergency response to a sustainable, country-owned response. The process of transition to country ownership is already underway in the Eastern Caribbean; the Office of the US Global AIDS Coordinator (OGAC) has advised the region that PEPFAR funding is being redirected away from the Eastern Caribbean toward Caribbean countries with high disease burden to strengthen services for key populations. This article seeks to highlight and apply lessons learned from other donor transitions to support a successful transition of HIV programs in the Eastern Caribbean. Based on a rapid review of both peer-reviewed and gray literature on donor transitions to country ownership in family planning, HIV, and other areas, we identified 48 resources that addressed key steps in the transition process and determinants of readiness for transition. Analysis of the existing literature revealed 6 steps that could help ensure successful transition, including developing a clear roadmap articulated through high-level diplomacy; investing in extensive stakeholder engagement; and supporting monitoring and evaluation during and after the transition to adjust course as needed. Nine specific areas to assess a country’s readiness for transition include: leadership and management capacity, political and economic factors, the policy environment, identification of alternative funding sources, integration of HIV programs into the wider health system, the institutionalization of processes, the strength of procurement and supply chain management, identification of staffing and training needs, and engagement of civil society and the private sector. In the Caribbean, key areas requiring strengthening to ensure countries in the region can maintain the gains made under PEPFAR include further engaging civil society and the private sector, building the capacity of NGOs to take on essential program functions, and maintaining donor support for targeted capacity building and long-term monitoring and evaluation efforts.

Introduction:
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.

Driven by high morbidity and mortality, weak health systems, weak governance, and poverty, many countries in sub-Saharan Africa have a multitude of projects led by government, nongovernmental organizations, and researchers trying to fill gaps. Unfortunately, although the rhetoric is usually to “institutionalize” the project, many of these projects often fail in what others call “pilotitis”1 —a situation in which projects are first piloted but not sustained or scaled up. This is a practice that many governments claim that they are tired of, but business as usual still continues. In this way, Uganda is no exception. As a result, despite proliferation of “high-impact” projects, child mortality remains high in Uganda, and the country is unlikely to achieve the Sustainable Development Goals related to child health. A recent United Nations report estimated that, despite marked progress, 74,000 children die every year in Uganda—the majority from preventable diseases.2 One of the main strategies that has the potential to make significant improvements to child health in sub-Saharan Africa is a strong district-led integrated community case management (iCCM) implementation.

Country ownership in development aid assumes that with recipient countries’ interest and participation, “owning” aid-funded initiatives will lead to more successful outcomes. But there is no universally accepted definition of country ownership. We conducted a systematic literature review to identify aspects of country ownership mentioned in peer-reviewed and gray literature, and identified four themes: 1) power and legitimacy; 2) commitment and responsibility 3) capacity; and 4) accountability. We also analyzed and compared similarities and differences in how different documents define these dimensions, with the results providing a framework for measuring country ownership of development initiatives. Measurement approaches must recognize that factors within and among these dimensions interact with one another in complex ways. Use of measures to identify steps toward more ownership entails conversations among stakeholders about necessary change.

Social enterprises driving toward systems change must undertake various partnerships along the way. The one partnership most reported as being key to the ability to achieve such change is one with government. So thousands of social enterprises embark, every day, on this journey—filled with opportunities and challenges now documented in a newly released Scaling Pathways study.

“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.

Introduction:
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.

Traditional approaches to development programming with fixed targets and outcomes do not fit complex problems where the pathway to achieve results differs in each context and evolves constantly. Adaptive programming improves responses to complex problems by identifying which solutions bring change. This paper reviews the theory behind adaptive programming approaches and introduces the ‘Pathways of Change’ tool for achieving sustainability results, developed for the multi-country Women’s Integrated Sexual Health programme. Qualitative data, using semi-structured interviews and group discussions from teams in over 17 countries in Africa and South Asia, are presented which examine the application of the Pathways of Change (PoC) tool focusing on successes and challenges across different intervention areas. The PoC responds to the need for a more practical adaptive programming tool that can be tailored to support flexibility in global health programme implementation while meeting donor requirements. Findings suggest that the PoC tool provides a flexible yet robust alternative to traditional monitoring frameworks and is able to facilitate adaptive, contextualised planning and monitoring for multi-country programmes. The PoC tool offers a solution to realise the ambitions of implementing adaptive programming within global health programmes and potentially beyond. KEYWORDS: Adaptive programming monitoring tools global health measurement

This article presents a synthesis of five country studies of the sustainability of U.S. government-funded health projects in Central America and Africa. The studies reviewed health projects with a comparative framework to determine which project activities had continued after the donor funding ceased. This review found that health projects in Africa were less firmly sustained than those in Central America. The studies then evaluated context factors and project characteristics that were related to the sustainability of the projects. The weak economic and political context of the African cases was found to inhibit sustainability in those countries, suggesting that broader development issues be addressed before donors expect significant sustainability of health projects in Africa. Even in Central America it was found that the strength of the institution implementing the project was an important variable for sustainability, suggesting that donor attention also be shifted toward strengthening institutional development in order to assure sustainability. In addition to context factors, several project characteristics were related to sustainability in most cases and suggest sustainability guidelines for project design and implementation. The article concludes that projects should be designed and managed so as to: (1) demonstrate effectiveness in reaching clearly defined goals and objectives; (2) integrate their activities fully into established administrative structures; (3) gain significant levels of funding from national sources (budgetary and cost-recovery) during the life of the project; (4) negotiate project design with a mutually respectful process of give and take; and (5) include a strong training component. sustainability Central America Africa donor assistance

This article presents a generic framework for understanding institutional sustainability in development. Its lessons draw from the agriculture and health sectors. The framework treats institutions as: (a) systems that function in relationship to their environments; (b) organized and managed entities whose organizational structures and procedures must match the tasks, products, people, resources, and contexts they deal with; and (c) settings intimately concerned with the exchange of resources where economic and political relationships intertwine to create varying patterns of power and incentive. Application of the analytic framework has shown that institutional sustainability depends upon maintaining: responsive output flows (high quality and valued goods and services); cost-effective goods and services delivery mechanisms (organization and management); and resource flows (recurrent costs, capital investments, human resources).

Background
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.

Despite many global efforts, malnutrition continues to persist worldwide. Malnutrition contributes to nearly one half of all deaths of children under five years of age (CU5) in developing countries.1,2 There is a need for those working in global nutrition to make coordinated investments in improving and testing large-scale and sustainable interventions if we are to reverse this trend and achieve Sustainable Development Goal (SDG) 2 (to end hunger, achieve food security and improved nutrition and promote sustainable agriculture)3. This will require testing ideas that are not only innovative, but also simple enough to scale in a variety of challenging contexts and that are cost-effective enough to be sustained beyond the life cycle of a single grant. Too many innovative ideas never leave the pilot phase because, while effective in isolated testing, they would be impossibly resource-intensive to implement on a large scale over time. The Eleanor Crook Foundation (ECF) wants to ensure its’ grantees are incorporating considerations of scalability and sustainability into their study designs so that potentially impactful ideas can move beyond the pilot phase and elicit large-scale reductions in malnutrition.

Background
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.

This document is intended to reflect on C-SAFE\'s collective experience with exit strategies, improve our understanding, and provide guidance to NGO staff for developing effective exit strategies in the field. The goal of this guidance document is to improve our collective understanding and ability to develop and implement sound exit strategies from developmental relief programs by: looking at some key concepts and terminology related to Exit Strategies (borrowed primarily from the FANTA technical note on Exit Strategies, November 2004); discussesing the challenges associated with Exit Strategies; incorporating special consideration of the southern Africa context - which includes a high prevalence of HIV/AIDS, recurrent droughts, unstable political environments, increasing poverty, and typically an environment of funding constraints; providing step-by-step guidance on how to develop, implement, and monitor sound Exit Strategies for Title II developmental relief programs; and reflecting on the experiences of C-SAFE member agencies in the region. Along with the case studies and examples, this document will assist C-SAFE NGO members in improving their understanding of exit strategies.

The multi-level perspective (MLP) has emerged as a fruitful middle-range framework for analysing socio-technical transitions to sustainability. The MLP also received constructive criticisms. This paper summarises seven criticisms, formulates responses to them, and translates these into suggestions for future research. The criticisms relate to: (1) lack of agency, (2) operationalization of regimes, (3) bias towards bottom-up change models, (4) epistemology and explanatory style, (5) methodology, (6) socio-technical landscape as residual category, and (7) flat ontologies versus hierarchical levels. Transitions Sustainable development Multi-level perspective Response to critics

Planning for programme sustainability is a key contributor to health and development, especially in low-income and middle-income countries. A consensus evidence-based operational framework would facilitate policy and research advances in understanding, measuring, and improving programme sustainability. We did a systematic review of both conceptual frameworks and empirical studies about health-programme sustainability. On the basis of the review, we propose that sustainable health programmes are regarded as complex systems that encompass programmes, health problems targeted by programmes, and programmes\' drivers or key stakeholders, all of which interact dynamically within any given context. We show the usefulness of this approach with case studies drawn from the authors\' experience.

The Need to Focus on Sustainability The Family Planning High Impact Practice (HIP) Initiative is focused on synthesizing evidence and learning on “what works” in family planning. The HIP organizes practices into three broad categories: service delivery, social and behavior change communication, and enabling environment (see website for more detail). The main role of the HIP Technical Advisory Group (TAG) is to offer an unbiased review of evidence on a specific practice in order to assess that practice’s potential to significantly improve family planning programs. The assessment of the evidence is based on a pre-determined set of criteria, such as impact on modern contraceptive use and sustainability (see HIP list for complete list of criteria). The TAG recognizes that the term, “sustainability,” is ill-defined and, to that end, requested a small group of TAG members to provide more specific guidance on how the HIP TAG should consider sustainability when determining if a practice meets the criteria to be labeled a High Impact Practice. Clearly, sustainability is a key concern among decision makers when deciding whether to invest in any specific HIP. The authors considered this issue by asking three key questions: 1) How is sustainability defined? 2) What evidence is required to demonstrate a practice is sustainable? 3) How can HIPs be implemented to increase the potential for sustainability for as long as the practice is relevant for the program? Evolving Definitions of Sustainability Over time, the definitions of sustainability have changed. In the 1990s, the term was used to refer to the ability of country family planning programs1-4 and non-governmental organizations (NGOs)5-7 to maintain gains after donors phased out. In the 1990s and 2000s, questions of sustainability focused on moving from pilot projects to scale up of and integration into existing programs or standardized practice. This includes the geographic expansion of programs, referred to as “horizontal scale-up,” and the inclusion of key implementation inputs into existing systems—such as training, tracking, and policies—referred to as “vertical scale-up” (see Figure 1). 8 The importance of “starting with the end in mind,” contributed to the development of approaches and tools.9-15 More recently, systems frameworks and tools have been developed for promoting “sustainable development,” defined by the World Commission on Environment and Development (WCED) as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs.” 16 Sustainable development has taken on increased salience in the face of climate change issues and the growing importance of building resilient systems. 2, 17-20 Appendix 1 provides a table showing the evolution of definitions of sustainability.

The Health of People and Environment–Lake Victoria Basin (HoPE–LVB), a cross-sectoral integrated Population, Health, and Environment (PHE) effort implemented by Pathfinder International and a range of partners in Kenya and Uganda during 2011-2019, aimed to improve interconnected health, environment, and development challenges in an ecologically biodiverse region. After an external evaluation in 2018 documented the results of the project, partners and donors were interested in learning about the ongoing sustainability of the project activities to draw lessons for designing future projects. Therefore in 2022, USAID through the Knowledge SUCCESS project, collaborated with a philanthropic partner, Preston-Werner Ventures, to conduct a rapid stock-taking exercise to explore the successes, challenges, and opportunities in scaling-up and sustaining the cross-sectoral programming. This learning brief features the voices from a range of stakeholders that were involved in the project to share their perspectives and knowledge on the scale-up and sustainability of HoPE-LVB activities.

The challenge of rural poverty and food insecurity in the developing world remains daunting. Recent estimates show that “there are still about 1.2 billion extremely poor people in the world. In addition, about 870 million people are undernourished, and about 2 billion people suffer from micronutrient deficiency. About 70 percent of the world’s poor live in rural areas, and many have some dependency on agriculture,” (Cleaver 2012). Addressing this challenge by assisting rural small-holder farmers in developing countries is the mandate of the International Fund for Agricultural Development (IFAD), an international financial institution based in Rome. The International Fund for Agricultural Development is a relatively small donor in the global aid architecture, accounting for approximately one-half of 1 percent of all aid paid directly to developing countries in 2010. Although more significant in its core area of agricultural and rural development, IFAD still accounts for less than 5 percent of total official development assistance in that sector.1 Confronted with the gap between its small size and the large scale of the problem it has been mandated to address, IFAD seeks ways to increase its impact for every dollar it invests in agriculture and rural development on behalf of its member states. One indicator of this intention to scale up is that it has set a goal to reach 90 million rural poor between 2012 and 2015 and lift 80 million out of poverty during that time. These numbers are roughly three times the number of poor IFAD has reached previously during a similar time span. More generally, IFAD has declared that scaling up is “mission critical,” and this scaling-up objective is now firmly embedded in its corporate strategy and planning statements. Also, increasingly, IFAD’s operational practices are geared towards helping its clients achieve scaling up on the ground with the support of its loans and grants. This was not always the case. For many years, IFAD stressed innovation as the key to success, giving little attention to systematically replicating and building on successful innovations. In this regard, IFAD was not alone. In fact, few aid agencies have systematically pursued the scaling up of successful projects. However, in 2009, IFAD management decided to explore how it could increase its focus on scaling up. It gave a grant to the Brookings Institution to review IFAD’s experience with scaling up and to assess its operational strategies, policies and processes with a view to strengthening its approach to scaling up. Based on an extensive review of IFAD documentation, two country case studies and intensive interactions with IFAD staff and managers, the Brookings team prepared a report that it submitted to IFAD management in June 2010 and published as a Brookings Global Working Paper in early 2011 (Linn et al. 2011).

Background:
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.

Background
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.

This article presents an informed definition of sustainability and an associated planning model for sustaining innovations (pertinent to both infrastructure and interventions) within organizational, community, and state systems. The planning model stems from a systematic review of the literature and from concepts derived from a series of ‘think tanks’ made up of key substance abuse prevention professionals. The model assumes a five-step process (i.e. assessment, development, implementation, evaluation, and reassessment/modification) and addresses factors known to inhibit efforts to sustain an innovation. One set of factors concerns the capacity of prevention systems to support sustainable innovations. The other pertains to the extent to which a particular innovation is sustainable. A sustainability action strategy is presented that includes goals with corresponding sets of objectives, actions, and results that determine the extent of readiness to sustain an innovation. Sustainability tools to assist in implementing the planning model are illustrated, and next steps for the model are discussed. This planning model provides a conceptual and practical understanding of sustainability that can lead to further investigation. Sustainability Planning Evaluation Innovation Prevention

The transition to higher-income status is a positive step forward for countries, but this transition brings with it the prospect of declining external assistance, both in general and in particular for health. Most health donor agencies rely at least in part on an income threshold to establish eligibility for support. Such a donor transition implies that government is increasingly responsible for the financing of a health programme and its supported interventions.1 However, focusing attention only on replacing external assistance with domestic revenues for the programmes concerned is problematic in two ways: firstly, this approach limits the sustainability question to revenues, and secondly, it limits the scope for action to the specific health programme that was receiving external support. The commitment countries have made to universal health coverage (UHC) is an opportunity to reframe the transition agenda towards sustaining coverage results rather than externally funded programmes per se. This perspective has implications for the overall approach to transition taken at both national and global levels. UHC embeds the goals of equity in service use, quality, and financial protection at the level of the entire health system and population.2 The way external resources are often channelled, as a legacy of the Millennium Development Goals era, creates or reinforces vertical structures focused on specific diseases or interventions. In many countries, these subsystems operate independently of the rest of the health system, with separate plans, budgets, funding, procurement, supply chains, and information systems.3 When viewed through a UHC lens (ie, across the health system, within which programmes are embedded), it is apparent that these separate subsystems duplicate responsibilities, compromising efficiency in resource use and sometimes effective case management—eg, when service use data on a pregnant woman who has HIV is managed separately by the HIV programme and the maternal health programme.4 Consolidating underlying subsystems can help sustain progress. External assistance should support such real system-building actions. Purely financial solutions to the challenges posed by donor transition, such as blended financing arrangements, should not mask the need to address these efficiency challenges that are at the core of putting national health systems on more sustainable trajectories. There is no need to wait for transition; the time to initiate such change is now.

The main challenge for a sustainability transition is to scale up successful solutions. Upscaling requires coalitions of public, private, and civil society actors who align their motivations. Pathways to upscaling may involve leveraging a dominant player’s market power, integrating successful initiatives into public policy, or reinforcing government-led change with private efforts. Various actors agree to collaborate to take advantage of their complementary capabilities, e.g., government policies facilitate private action, market incentives reward progressive actors while government sanctions punish laggards, actors take up different tasks of the policy cycle, and large players absorb and disseminate pioneer efforts. To achieve durable impacts, the upscaling of solutions to reach sustainability must continually maintain a balance of incentives among key actors. We identify general lessons for successful upscaling that provide insights on the importance of motivating actors, designing collaborations for lasting success, and incorporating concerns of developing countries.

An international aid program is a process that takes complex strategic planning with persistent collective efforts. Although dependent on a program’s nature, many international aid programs seek sustained benefits and services as their eventual goal after a donor funding ceases. Accordingly, sustainability of international aid programs has been much discussed for aid effectiveness and efficiency. Despite its well-recognized importance, and due to its complexity, the term ‘sustainability’ has yet to be clearly conceptualized across even similar programs. Additionally, there seems to be a lack of consensus on what common factors may contribute to sustainability. The current study reviewed 16 select papers of international aid programs related to health, food or rural development, and identified commonly utilized working concepts of sustainability and its key factors. The most cited concept of sustainability in the select papers was sustained delivery of program services and outcomes. For its contributing factors, eleven factors were identified in the order of frequency: capacity building (16), political commitment (10), continuous funding resource (8), community participation (6), linkage or connectedness (5), acceptance in socio-culture (5), program effectiveness (5), institutionalization (3), transition of responsibility (3), negotiation (3) and communication (3). The findings can help plan more sustainable programs in relevant fields. Key words: sustainability, factors, sustained benefit, continued impact, aid program, international development

Background
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.

Background
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.

Background
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.

In public health, programs constitute an important method of improving health, and program sustainability is critical. Knowledge on sustainability raises nevertheless two major issues. The first concerns the social structures within which programs are sustained. The literature suggests different structures however only organizational structures, namely routines, are used for analysis. The second issue concerns the temporal aspect of sustainability that is typically conceived as the final phase of program development after the planning, implementation, and evaluation phases. This ‘stage’ model does not allow one to consider that sustainability must be prepared in advance, concomitantly with implementation. These structural and temporal dimensions ground our proposal to re-conceive sustainability. The literature on organizations defines two relevant social structures, one organizational (routines), and one institutional (standards). This in turn suggests three degrees of sustainability. We then emphasize how sustainability is concomitant with the implementation process, by exploring events that characterize these processes. Health promotion programs Implementation Institutionalization Organizational learning Routinization Sustainability

Background
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.

Expansion of community health services in Rwanda has come with the national scale up of integrated Community Case Management (iCCM) of malaria, pneumonia and diarrhea. We used a sustainability assessment framework as part of a large-scale project evaluation to identify factors affecting iCCM sustainability (2011). We then (2012) used causal-loop analysis to identify systems determinants of iCCM sustainability from a national systems perspective. This allows us to develop three high-probability future scenarios putting the achievements of community health at risk, and to recommend mitigating strategies. Our causal loop diagram highlights both balancing and reinforcing loops of cause and effect in the national iCCM system. Financial, political and technical scenarios carry high probability for threatening the sustainability through: (1) reduction in performance-based financing resources, (2) political shocks and erosion of political commitment for community health, and (3) insufficient progress in resolving district health systems--“building blocks”--performance gaps. In a complex health system, the consequences of choices may be delayed and hard to predict precisely. Causal loop analysis and scenario mapping make explicit complex cause-and-effects relationships and high probability risks, which need to be anticipated and mitigated. Sustainability Causal loop analysis Community case management Evaluation Health systems Rwanda Systems thinking Community health

This manual is designed to assist project managers, planners, and evaluators in their efforts to improve their approaches to planning for and assessing sustainability in health projects implemented in developing countries. It is intended as a practical guide for health project managers, especially those implementing community health projects in resource-constrained settings. It focuses on a specific framework, the Sustainability Framework (SF), developed through the U.S. Agency for International Development’s (USAID) Child Survival and Health Grants Program (CSHGP). This manual represents the collective learning of about 30 projects that have applied and helped refine it over a 7-year period, many of them CSHGP-funded projects. It has been used for project planning, monitoring, end-of-project evaluation, and post-project evaluation.

Background
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.

Funders of programs in public health and community health are increasingly concerned about the sustainability of changes they initiate. Despite a recent increase in sustainability research and evaluation, this literature has not developed a widely used paradigm for conducting research that can accumulate into generalizable findings. We provide guidance for research and evaluation of health program sustainability, including definitions and types of sustainability, specifications and measurements of dependent variables, definitions of independent variables or factors that influence sustainability, and suggestions for designs for research and data collection. We suggest viewing sustainability research as a further stage in the translation or dissemination of research-based interventions into practice. This perspective emphasizes ongoing relationships with earlier stages of a broader diffusion framework, including adoption and implementation processes.

Evaluative research for questions of program sustainability has expanded substantially in recent years, but definitional issues remain. This paper presents definitions for four different types of sustainability as potential outcomes of health programs. We then illustrate these definitions with descriptive findings from an on-line survey to “look back” at the extent and types of sustainability that occurred among 48 community-based projects that had received short-term funding from a foundation-funded health program in New Jersey. We found that large percentages of respondents reported positively to each of four types of sustainability measures—maintaining program activities, continuing to serve substantial numbers of clients, building and sustaining collaborative structures, and maintaining attention to the ideas underlying the projects by disseminating them to others. Strengths and limitations of this methodology for future evaluation are also discussed. Evaluating sustainability Health programs On-line survey Organizational capacity Dissemination

Attention to the sustainability of health intervention programs both in the US and abroad is increasing, but little consensus exists on the conceptual and operational definitions of sustainability. Moreover, an empirical knowledge base about the determinants of sustainability is still at an early stage. Planning for sustainability requires, first, a clear understanding of the concept of sustainability and operational indicators that may be used in monitoring sustainability over time. Important categories of indicators include: (1) maintenance of health benefits achieved through an initial program, (2) level of institutionalization of a program within an organization and (3) measures of capacity building in the recipient community. Second, planning for sustainability requires the use of programmatic approaches and strategies that favor long-term program maintenance. We suggest that the potential influences on sustainability may derive from three major groups of factors: (1) project design and implementation factors, (2) factors within the organizational setting, and (3) factors in the broader community environment. Future efforts to develop sustainable health intervention programs in communities can build on the concepts and strategies proposed here.

There is strong interest in implementation science to address the gap between research and practice in public health. Research on the sustainability of evidence-based interventions has been growing rapidly. Sustainability has been defined as the continued use of program components at sufficient intensity for the sustained achievement of desirable program goals and population outcomes. This understudied area has been identified as one of the most significant translational research problems. Adding to this challenge is uncertainty regarding the extent to which intervention adaptation and evolution are necessary to address the needs of populations that differ from those in which interventions were originally tested or implemented. This review critically examines and discusses conceptual and methodological issues in studying sustainability, summarizes the multilevel factors that have been found to influence the sustainability of interventions in a range of public health and health care settings, and highlights key areas for future research. adaptation, evidence-based interventions, implementation science, maintenance, sustainability

Background
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.

Scale, impact, cost-efficiency and sustainability are the four interlocking tenets that characterize The Challenge Initiative (TCI). At the heart of TCI’s philosophy is the belief that scaling global health interventions without impact is empty scale; that impact at scale without simultaneously increasing cost-efficiencies is not viable; and that cost-efficient impact at scale that is not sustained will not produce lasting change. TCI delivers on all four tenets, understanding that one without the other three is inadequate to achieve enduring progress.

Sustainable service delivery is a major challenge in the HIV response that is often not adequately addressed in project implementation. Sustainable strategies must be built into project design and implementation to enable HIV efforts to continue long after donor-supported projects are completed. This paper presents the experiences in operational sustainability of Family Health International\'s Zambia Prevention, Care and Treatment Partnership in Zambia, which is supported by the US President\'s Emergency Plan for AIDS Relief through United States Agency for International Development (October 2004 to September 2009). The partnership worked with Zambia\'s Ministry of Health to scale up HIV clinical services in five of the country\'s nine provinces, reaching 35 districts and 219 facilities. It provided technical and financial support from within the ministry\'s systems and structures. By completion of the project, 10 of the 35 districts had graduated beyond receiving ongoing technical support. By working within the ministry\'s policies, structures and systems, the partnership was able to increase the ministry\'s capacity to add a comprehensive HIV service delivery component to its health services. Ministry structures were improved through renovations of health facilities, training of healthcare workers, procurement of essential equipment, and establishment of a quality assurance plan to ensure continued quality of care. The quality assurance tools were implemented by both the ministry and project staff as the foundation for technical graduation. Facilities that met all the quality criteria for more than six months were graduated from project technical support, as were districts where most supported facilities met the criteria. The district health offices then provided ongoing supervision of services. This predetermined \"graduation\" exit strategy, with buy in of the provincial and district health offices, set the stage for continued delivery of high-quality HIV services. Achieving operational sustainability in a resource-limited setting is feasible. Developing and institutionalizing a quality assurance/quality improvement system is the basis on which facilities and districts can move beyond project support and, therefore, sustain services. Quality assurance/quality improvement tools should be based on national standards, and project implementation should use and improve existing health system structures.

The Health of People and Environment in the Lake Victoria Basin (HoPE-LVB) Project workshop for Dissemination and Strategic Planning for Scale up, organized by Pathfinder International Kenya, was held in Kisumu from 11-12 February 2015.
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

The current scholarly focus on implementation science is meant to ensure that public health interventions are effectively embedded in their settings. Part of this conversation includes understanding how to support the sustainability of beneficial interventions so that limited resources are maximised, long-term public health outcomes are realised, community support is not lost, and ethical research standards are maintained. However, the concept of sustainability is confusing because of variations in terminology and a lack of agreed upon measurement frameworks, as well as methodological challenges. This commentary explores the challenges around the sustainability of public health interventions, with particular attention to definitions and frameworks like Normalization Process Theory and the Dynamic Sustainability Framework. We propose one important recommendation to direct attention to the sustainability of public health interventions, that is, the use of theoretically informed approaches to guide the design, development, implementation, evaluation and sustainability of public health interventions.

The Program Sustainability Assessment Tool (PSAT) is a self-assessment used by both program staff and stakeholders to evaluate the sustainability capacity of a program. When you take the assessment online, you will receive a summary report of your overall sustainability, which can be used to help with sustainability planning. The first Program Sustainability Framework was developed with funding from the National Association of Chronic Disease Directors. Revision and distribution of the tool is funded by the Centers for Disease Control, Office on Smoking and Health. Understand the factors that influence a program’s capacity for sustainability. Use the Program Sustainability Assessment Tool to assess your program’s capacity for sustainability. View results from your assessment as a Sustainability report. Develop an Action Plan to increase the likelihood of sustainability.

Around two-thirds of all new HIV infections and 90% of syphilis cases occur in low- and middle-income countries (LMICs). Testing is a key strategy for the prevention and treatment of HIV and syphilis. Decision-makers in LMICs face considerable uncertainties about the costs of scaling up HIV and syphilis testing. This paper synthesizes economic evidence on the costs of scaling up HIV and syphilis testing interventions in LMICs and evidence on how costs change with the scale of delivery. We systematically searched multiple databases (Medline, Econlit, Embase, EMCARE, CINAHL, Global Health and the NHS Economic Evaluation Database) for peer-reviewed studies examining the costs of scaling up HIV and syphilis testing in LMICs. Thirty-five eligible studies were identified from 4869 unique citations. Most studies were conducted in Sub-Saharan Africa (N = 17) and most explored the costs of rapid HIV in facilities targeted the general population (N = 19). Only two studies focused on syphilis testing. Seventeen studies were cost analyses, 17 were cost-effectiveness analyses and 1 was cost–benefit analysis of HIV or syphilis testing. Most studies took a modelling approach (N = 25) and assumed costs increased linearly with scale. Ten studies examined cost efficiencies associated with scale, most reporting short-run economies of scale. Important drivers of the costs of scaling up included testing uptake and the price of test kits. The ‘true’ cost of scaling up testing is likely to be masked by the use of short-term decision frameworks, linear unit-cost projections (i.e. multiplying an average cost by a factor reflecting activity at a larger scale) and availability of health system capacity and infrastructure to supervise and support scale up. Cost data need to be routinely collected alongside other monitoring indicators as HIV and syphilis testing continues to be scaled up in LMICs. Scales, costs, review, healthcare costs Topic: hiv cost-benefit analysis syphilis developing countries medline world health economic shiv infections syphilis and hiv health care systems

The lack of access to quality-assured surgery in rural parts of sub-Saharan Africa, where the numbers of trained health workers are often insufficient, presents challenges for national governments. The case for investing in scaling up surgical systems in low-resource settings is 3-fold: the potential beneficial impact on a large proportion of the global burden of disease; better access for rural populations who have the greatest unmet need; and the economic case. The economic losses from untreated surgical conditions far exceed any expenditure that would be required to scale up surgical care. We identified the resources used in delivering surgery at a rural district-level hospital and an urban based referral hospital in Zambia and calculated their cost through a combination of bottom-up costing and step-down accounting. Surgery performed at the referral hospital is ∼50% more expensive compared with the district hospital, mostly because of the higher cost of hospital stay. The low bed occupancy rates at the two hospitals suggest underutilization of the capacity, and/or missing elements of needed capacity, to conduct surgery. Nevertheless, our study confirms that scaling up district-level surgery makes sense, through bringing economies of scale, while acknowledging the need for more comprehensive assessments and costing of capacity constraints. We quantified the economies of scale under different scaling scenarios. If surgery at the district hospital was scaled up by 10, 20 or 50%, the total cost of surgery would increase proportionately less than that, i.e. by 6, 12 and 30%, respectively. If this were to lead to less demand for surgery at the referral hospital, say 10% less surgery, it would result in a reduction of 2.7% in the total cost. Although the health system as a whole would benefit, the referring hospitals would not derive the full economic benefit, unless Government increased resources for district-level surgery. Global surgery, rural, district hospital, cost, scaling up

Senegal is a country with a long tradition of supporting development, in particular because of its political stability. The Senegalese context is particularly favored by donors, and in particular by the World Bank, which saw in it an opportunity to test a new combination of what has been one of its flagship interventions in the region for several years now: results-based financing (RBF).

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.

Resources to support sustainable financing of family planning programs in developing countries.

Most service delivery interventions begin as pilot projects. When a pilot study of an intervention is successful, managers begin to think about scaling up the project to new areas. Cost is a critical factor influencing the extent and pace of scale-up. This brief explains how to adapt and modify cost information obtained from a pilot project to estimate scaleup costs. The brief shows why the costs of a pilot project alone are not sufficient to predict costs of scale-up, and gives examples of how costs are influenced by factors like economies and diseconomies of scale, resource substitution, and intervention modification. The purpose of the brief is not to provide a “cookbook” for estimating scale-up costs. Rather, it is designed to help managers think critically about the factors that must be considered in estimating the costs of scaling up an effective intervention. This brief discusses factors that program managers need to consider when scaling up pilot projects. The first decision is whether to scale up the pilot project at all. There should be evidence that the pilot project proved successful and its success should be achieved at reasonable cost. Not all pilot projects are candidates for scale-up, either because they are found to be ineffective or because they are not affordable; in other words, they have low cost effectiveness. Understanding the factors that affect the costs of scaling up will encourage better decisions about the extent and pace of the scale-up. The term “scaling up” may be used to describe several different methods of expanding a program; this brief uses the term to indicate expansion of a pilot project to new locations.2 Although the examples in this brief are drawn from a reproductive health project, the principles discussed apply to other types of health projects as well. Organizations often track costs of interventions in pilot projects. While it may seem logical to simply extrapolate those costs to additional sites, the relationship between costs in a pilot project and costs in a scale-up is not so straightforward. The costs of serving a large population will probably not be a simple proportional increase in the costs of the pilot project. However, with some adjustments, the costs of the pilot project can be used to estimate scale-up costs.

Recent studies such as the Commission on Macroeconomics and Health have highlighted the need for expanding the coverage of services for HIV/AIDS, malaria, tuberculosis, immunisations and other diseases. In order for policy makers to plan for these changes, they need to analyse the change in costs when interventions are 'scaled-up' to cover greater percentages of the population. Previous studies suggest that applying current unit costs to an entire population can misconstrue the true costs of an intervention. This study presents the methodology used in WHO-CHOICE's generalised cost effectiveness analysis, which includes non-linear cost functions for health centres, transportation and supervision costs, as well as the presence of fixed costs of establishing a health infrastructure. Results show changing marginal costs as predicted by economic theory.

National governments and international agencies, including programmes like the Global Alliance for Vaccines and Immunizations and the Global Fund to Fight AIDS, Tuberculosis and Malaria, have committed to scaling up health interventions and to meeting the Millennium Development Goals (MDGs), and need information on costs of scaling up these interventions. However, there has been no systematic attempt across health interventions to determine the impact of scaling up on the costs of programmes. This paper presents a systematic review of the literature on the costs of scaling up health interventions. The objectives of this review are to identify factors affecting costs as coverage increases and to describe typical cost curves for different kinds of interventions. Thirty-seven studies were found, three containing cost data from programmes that had already been scaled up. The other studies provide either quantitative cost projections or qualitative descriptions of factors affecting costs when interventions are scaled up, and are used to determine important factors to consider when scaling up. Cost curves for the scaling up of different health interventions could not be derived with the available data. This review demonstrates that the costs of scaling up an intervention are specific to both the type of intervention and its particular setting. However, the literature indicates general principles that can guide the process: (1) calculate separate unit costs for urban and rural populations; (2) identify economies and diseconomies of scale, and separate the fixed and variable components of the costs; (3) assess availability and capacity of health human resources; and (4) include administrative costs, which can constitute a significant proportion of scale-up costs in the short run. This study is limited by the scarcity of real data reported in the public domain that address costs when scaling up health interventions. As coverage of health interventions increases in the process of meeting the MDGs and other health goals, it is recommended that costs of scaling up are reported alongside the impact on health of the scaled-up interventions. health care costs, health care delivery, scaling up, review

There is growing evidence that community financing mechanisms can raise additional revenue, increase equitable access to primary health care (PHC), and improve social protection. More recently there has been interest in scaling up community financing as a step towards universal coverage either via tax-based systems or social health insurance. Using key informant interviews and focus group discussions, this study sought to assess the desirability and feasibility of scaling-up community health insurance in Armenia. The results suggest that there is broad-based political support for scaling up the schemes and that community financing is synergistic with major health sector reforms. High levels of social capital within the rural communities should facilitate scaling up. Existing schemes have increased access and quality of care, but expansion of coverage is constrained by affordability, poor infrastructure, and weak linkages with the broader health system. Long-term subsidies and system-building will be essential if the expanded schemes are to be financially viable and pro-poor. Overall, successfully scaling up community financing in Armenia would depend on addressing a range of obstacles related to legislation, institutional capacity, human resources and resistance to change among certain stakeholders. Community-based health financing / insurance Scaling up Decision making Armenia Low income

Background
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.

India has announced the ambitious program to transform the current primary healthcare facilities to health and wellness centres (HWCs) for provision of comprehensive primary health care (CPHC). We undertook this study to assess the cost of this scale-up to inform decisions on budgetary allocation, as well as to set the norms for capitation-based payments. The scale-up cost was assessed from both a financial and an economic perspective. Primary data on resources used to provide services in 93 sub-health centres (SHCs) and 38 primary health care centres (PHCs) were obtained from the National Health System Cost Database. The cost of additional infrastructure and human resources was assessed against the normative guidelines of Indian Public Health Standards and the HWC. The cost of other inputs (drugs, consumables, etc.) was determined by undertaking the need estimation based on disease burden or programme guidelines, standard treatment guidelines and extent and pattern of care utilization from nationally representative sample surveys. The financial cost is reported in terms of the annual incremental cost at health facility level, as well as its implications at national level, given the planned scale-up path. Secondly, economic cost is assessed as the total annual as well as annual per capita cost of services at HWC level. Bootstrapping technique was undertaken to estimate 95% confidence intervals for cost estimations. Scaling to CPHC through HWC would require an additional ₹ 721 509 (US$10 178) million allocation of funds for primary healthcare >5 years from 2019 to 2023. The scale-up would imply an addition to Government of India’s health budget of 2.5% in 2019 to 12.1% in 2023. Our findings suggest a scale-up cost of 0.15% of gross domestic product (GDP) for full provision of CPHC which compares with current public health spending of 1.28% of GDP and a commitment of 2.5% of GDP by 2025 in the National Health Policy. If a capitation-based payment system was used to pay providers, provision of CPHC would need to be paid at between ₹ 333 (US$4.70) and ₹ 253 (US$3.57) per person covered for SHC and PHC, respectively. cost, scale-up, primary health care, universal health coverage, health and wellness centre

Objective:
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.

This document provides information on the methods, key parameters and underlying assumptions used to estimate the costs of expanding the coverage of skilled maternal and newborn health (MNH) care at facilities towards universal access, which is defined here as 95% coverage. The costs include activities assessed to be crucial in strengthening maternal and newborn health care services to improve health and reduce morbidity and mortality in 75 key countries. The selected countries account for the majority of the maternal and newborn ill-health and mortality burden in low and middle-income countries. Costs were calculated annually, from 2006 to 2015, and per country based on a bottom-up ingredients approach in order to estimate the additional resources needed to provide 67 key MNH interventions and services. The total incremental costs for the entire period were estimated at US$ 39 billion, in addition to current expenditure, increasing from US$ 1 billion in 2006, as coverage expands, to US$ 6.1 billion in 2015. This would mean an additional US$ 0.22 per inhabitant per year initially, expanding to US$ 1.18 in 2015. If this scale-up scenario is implemented, significant steps will have been taken in every country in reducing maternal mortality and at a global level the Millennium Development Goal 5 for improving maternal health could potentially be achieved. CAH (Department of ) Child and Adolescent Health and Development CMH Commission of Macroeconomics and Health DHS Demographic and Health Survey EHTP Essential Health Technology Package EIP Evidence and Information for Policy FP Family Planning GAVI Global Alliance for Vaccines and Immunization GBD Global Burden of Disease HRH Human Resources for Health HSC Health System Constraints IMPAC Integrated Management of Pregnancy and Childbirth IUD Intrauterine device MCH Mother and Child Health MDG Millennium Development Goals M&E Monitoring and evaluation MNH Maternal and Newborn Health MMR Maternal Mortality Ratio MPS (Department of ) Making Pregnancy Safer OB/GYN Obstetrics/Gynaecology PMTCT Prevention of mother-to-child transmission PPC Post-partum care PPP Purchasing Power Parity RBM Roll Back Malaria Global Partnership SBA Skilled Birth Attendant STI Sexually Transmitted Infection UN Pop UN Population Division UNFPA United Nations Population Fund UNICEF United Nations Childrens Fund VCT Voluntary counselling and testing WHO World Health Organization WHR World Health Report

Overall, family planning—as an evidence-based intervention with a high return on investment— is included in GFF-financed projects. However, it is not always visible because it is most often integrated into service delivery programs (including RBF projects), and is a regular component of health commodity procurement. Because the PADs are usually purposefully designed to be quite broad, it is up to family planning stakeholders to play a role at key times of the GFF process, including in the development of the RBF/operations manual and annual workplans, which tend to have much less visibility than the investment case development process; the investment case has more clearly defined procedures for involving civil society and family planning program managers. In part because GFF funding is not siloed and does not come with any built-in restrictions, it can be used for almost anything related to RMNCAH-N. This aspect is positive for family planning advocates, in that there is no cap on the total funding for family planning interventions and no specific components are excluded. If successful, advocates can help their countries leverage GFF funding to better support family planning. Using lessons learned from this brief, family planning stakeholders can better understand the GFF process and how to play a role at key points to ensure that family planning priorities are appropriately included.

Several resources have been developed to assist program implementers with the process of scaling up. However, once scale-up is underway, few resources exist to help ensure continuous and systematic monitoring of the process to track progress toward sustainability of these innovations. This guide is intended to provide governments, donors, country organizations, and implementing partners with a low cost and replicable approach to monitoring the process of scaling up innovations in health.

Purpose:
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.

PEPFAR's focus on optimizing impact is a driving force behind global efforts to reach HIV epidemic control. PEPFAR is partnering with the international community to accelerate towards the UNAIDS 95-95-95 global goals: 95 percent of people living with HIV know their HIV status, 95 percent of people who know their HIV status are accessing treatment, and 95 percent of people on treatment have suppressed viral loads. Progress towards epidemic control will be successfully measured, in part, through an effective strategic information framework that not only monitors program outputs, but also key outcomes and programmatic impact.

Evaluating complex interventions is complicated. The Medical Research Council\'s evaluation framework (2000) brought welcome clarity to the task. Now the council has updated its guidance Complex interventions are widely used in the health service, in public health practice, and in areas of social policy that have important health consequences, such as education, transport, and housing. They present various problems for evaluators, in addition to the practical and methodological difficulties that any successful evaluation must overcome. In 2000, the Medical Research Council (MRC) published a framework1 to help researchers and research funders to recognise and adopt appropriate methods. The framework has been highly influential, and the accompanying BMJ paper is widely cited.2 However, much valuable experience has since accumulated of both conventional and more innovative methods. This has now been incorporated in comprehensively revised and updated guidance recently released by the MRC (www.mrc.ac.uk/complexinterventionsguidance). In this article we summarise the issues that prompted the revision and the key messages of the new guidance. Summary points The Medical Research Council guidance for the evaluation of complex interventions has been revised and updated The process of developing and evaluating a complex intervention has several phases, although they may not follow a linear sequence Experimental designs are preferred to observational designs in most circumstances, but are not always practicable Understanding processes is important but does not replace evaluation of outcomes Complex interventions may work best if tailored to local circumstances rather than being completely standardised Reports of studies should include a detailed description of the intervention to enable replication, evidence synthesis, and wider implementation

Despite massive donor investment in demand-side governance since 2000, the evidence-base on impact and effective approaches remains weak. In recent years, in the context of increased pressure from donors to demonstrate results, the search has been on for more credible and reliable ways of demonstrating effectiveness. There is a tension, however, between results agenda requirements for short-term, quantifiable and attributable results and the long-term, complex nature of governance reform. Linear results frameworks, with pre-planned quantitative targets and milestones, carry the danger of distorting and rigidifying what empowerment and accountability (E&A) programmes are aiming to do and achieve; undermining rather than facilitating the achievement of meaningful results. There is a growing movement of development academics and practitioners interested in ‘doing development differently’, partly in response to the distortions and perverse incentives associated with implementation of the results agenda. Their conclusions are built on a body of case studies, including SAVI, which demonstrate that achieving results in relation to complex development challenges such as governance reform requires locally led, politically smart and adaptive ways of working. This calls for innovation in approaches to monitoring and evaluation (M&E) to facilitate iterative learning processes, to define and monitor results that are not predictable in advance, and to learn more about how change happens in order to replicate and scale up successful approaches. SAVI’s approach to M&E has evolved through reflective practice since the programme started in FRONT COVER Citizens taking part in local radio programmes in Kano, Northern Nigeria • Photograph: George Osodi/SAVI 2 2008, building on lessons learnt in predecessor programmes. Key innovations are allowing programme staff and partners to be adaptive and flexible, and capture unexpected and less tangible results. This paper shares SAVI’s experience, learning and challenges as a contribution to current debates. It starts with a brief review of evolving thinking on measuring results. It goes on to explain SAVI’s overall approach to M&E describing the key tools used, and concludes with an analysis of learning and ongoing challenges.

Working with implementation partners in five focus countries (Democratic Republic of the Congo (DRC), Guatemala, India, Mali, and Rwanda), Georgetown University’s Institute for Reproductive Health (IRH) undertook the challenge of scaling up the Standard Days Method® (SDM) of FP (see sidebar)—and doing it right. IRH’s approach differs from the above examples in important ways. Specifically, IRH has found that successful scale-up requires careful planning, a systems approach, evidence-based practices and flexibility as situations evolve. These are core principles of the ExpandNet/WHO framework of scaling up that IRH has adopted to guide the scale-up process. The framework also calls for transparency, effective partnerships, stakeholder involvement from the beginning, and supporting scale-up through research, monitoring, learning and evaluation (MLE) throughout the process.

IRH recently completed a 5-year prospective case study of scaling up SDM in the Democratic Republic of the Congo, Guatemala, India (Jharkhand), Mali, and Rwanda. These studies, guided by the systems-oriented ExpandNet framework, have yielded a set of evidence-informed practices, methods, and tools to support M&E during the scaling up phase. These practices and tools have facilitated IRH’s efforts to bridge the ‘science–to-service’ gap in scale-up and have been adapted and presented here for the benefit of other organizations. As a companion to the guidance and tools, this introduction presents relevant implementation and scale-up theory and conveys the critical importance of integrating and balancing process monitoring and outcome evaluation into each element of the scale-up process, starting from the early planning stages.

Although a wealth of tested, practical methods, tools, and guidelines exist for planning, monitoring, and evaluating project-based sexual and reproductive health (SRH) interventions, there is less guidance for best practices to support scale-up efforts. While donors and governments are increasingly demanding the scale-up of evidence-based practices, products, and approaches, the reality is that many interventions that have been taken to scale do not sustain their effects once project funding ends. There is growing realization that inadequate attention has been paid to systems issues that support successful and sustainable scale-up. Organizations undertaking systems-oriented approaches to scale-up will find few tested, practical tools and guidelines to monitor and evaluate scale-up of an innovation within a complex health system. In the context of FP2020, which strives to reach 120 million women with lifesaving family planning (FP) information, services, and supplies in by 2020, a more complete road map for learning from monitoring and evaluating the introduction and scale-up of new FP methods and approaches is critical. Georgetown University’s Institute for Reproductive Health (IRH), through its global FAM Project (Fertility Awareness-based Methods Project, 2007-2013), worked with partners in five countries to design and guide scale-up of a new FP method – the Standard Days Method ® (SDM) - into FP programs and health systems and to use rigorous Monitoring, Learning, and Evaluation (MLE) to guide scale-up, from the design phase through implementation and evaluation phases. Guided and informed by the systemsoriented approach espoused in the ExpandNet scale-up framework, this compendium represents a distillation of knowledge and tools for scale-up MLE developed and used by IRH to provide stakeholders timely monitoring information to inform scale-up decisions, learn throughout the process, and evaluate achievements. We have developed this compendium to share our experiences and contribute to the growing evidence base on MLE of the scale-up process.

There is no guarantee that a successful pilot program introducing a reproductive health innovation can also be expanded successfully to the national or regional level, because the scaling-up process is complex and multilayered. This article describes how a successful pilot program to integrate the Standard Days Method (SDM) of family planning into existing Ministry of Health services was scaled up nationally in Rwanda. Much of the success of the scale-up effort was due to systematic use of monitoring and evaluation (M&E) data from several sources to make midcourse corrections. Four lessons learned illustrate this crucially important approach. First, ongoing M&E data showed that provider training protocols and client materials that worked in the pilot phase did not work at scale; therefore, we simplified these materials to support integration into the national program. Second, triangulation of ongoing monitoring data with national health facility and population-based surveys revealed serious problems in supply chain mechanisms that affected SDM (and the accompanying CycleBeads client tool) availability and use; new procedures for ordering supplies and monitoring stockouts were instituted at the facility level. Third, supervision reports and special studies revealed that providers were imposing unnecessary medical barriers to SDM use; refresher training and revised supervision protocols improved provider practices. Finally, informal environmental scans, stakeholder interviews, and key events timelines identified shifting political and health policy environments that influenced scale-up outcomes; ongoing advocacy efforts are addressing these issues. The SDM scale-up experience in Rwanda confirms the importance of monitoring and evaluating programmatic efforts continuously, using a variety of data sources, to improve program outcomes.

Consultation Aim and Objectives The consultation described in this report marks the beginning of IRH’s efforts to share experiences in the area of scale-up monitoring and evaluation more widely. The background paper and the presentation developed by IRH staff with the assistance of Amanda Fixsen, entitled “Monitoring and Evaluation of Scale-up: Theory and Practical Implications” (Appendix C), set the stage for the meeting. The technical consultation brought together 30 program practitioners, academics, researchers, and evaluators from USAID, UN agencies, foundations, universities, research organizations, and NGOs (see Appendix A for full list of participants) to: IRH: M&E of Scale Up Technical Consultation Report | 5 Foster thinking on practices for monitoring processes and evaluating outcomes of scaleup of health innovations; Articulate in practical terms the gaps and opportunities for improvement of the practice of M&E of scale-up; and Offer input into products that IRH should develop for wide dissemination that will contribute to advancing good practice on M&E of scale-up, including feedback on M&E tools developed by IRH for the case study on scaling up SDM. Specifically, six key questions guided discussions about M&E practice during the scale-up period: 1. What is the current evidence base about good practices in the M&E of scale-up? What are the knowledge gaps? 2. How does M&E of scale-up differ from M&E during pilots? From M&E of practices that are operating at scale? 3. Integrating planning and M&E to strengthen scale-up processes: How can M&E be implemented so that it supports scale-up rather than merely measures it? 4. Given the importance of integrating values such as gender and equity into the scale-up process, how can they be monitored and evaluated? 5. Because successful scale-up requires support from a wide range of stakeholders and decision makers, how can M&E meet their needs for timely information? How, and by whom, should this information be shared so that stakeholders and decision makers value and act on it? 6. What kind of guidance documents should IRH produce that would be most useful to complement ongoing efforts in M&E of scale-up?

Complexity-aware monitoring complements traditional monitoring methods by taking into account the uncertain and changing nature of complex situations. Methods that are \"complexity-aware\" enable us to address the inherent complexity of development programs when there are many competing variables, environments are uncertain, the causal pathways to outcomes are unclear, and stakeholders bring diverse perspectives. Within the MOMENTUM suite of awards, many interventions will be complex. The Guide to Complexity-aware Monitoring Approaches for MOMENTUM Projects builds on the MOMENTUM Monitoring, Evaluation, and Learning (MEL) Framework. The guide helps MOMENTUM implementing partners, their counterparts at USAID, and other users compare and select from nine complexity-aware monitoring approaches to answer key questions on outcomes related to the project causal framework and factors that contribute to outcomes. It will help programs test critical assumptions and adjust program implementation promptly when needed. WHEN TO USE COMPLEXITY-AWARE MONITORING Complexity-aware monitoring approaches help answer several key questions that are often missing from traditional monitoring approaches or, because of the complexity of the situation, cannot be answered with traditional approaches. These include: What outcomes, especially unintended outcomes, might be missing from the project causal framework? Moreover, innovations in projects or unstable environments could make project outcomes hard to predict. Methods to capture these unintended outcomes are useful, especially in complex projects. What outcomes might yet emerge? When the time between project outputs and outcomes is long, complexity-aware monitoring can help identify interim milestones that mark progress towards outcomes that are yet to emerge fully. For example, if the intended outcome is to implement an intervention at scale in a country, progress markers might include the percentage of districts implementing the intervention. How do stakeholders, including marginalized and underrepresented groups, perceive the project or intervention? Project implementers can use the perception of stakeholders (e.g., regional leadership, doctors and nurses, other staff, patients, and community members) regarding a quality improvement intervention in health facilities and its outcomes to validate findings from a quantitative review of routine service statistics. What factors contributed to the observed outcomes? Project implementers can identify outcomes and then trace them back to the specific interventions that likely contributed to those outcomes. Building this association is especially relevant when external stakeholders make significant contributions. What is happening in the broader context? Considering how stakeholders interact with each other, how information flows among them, and who influences them is relevant. This approach can help the project more efficiently target its efforts and monitor progress towards change.uncertain and changing nature of complex situations. Methods that are \"complexity-aware\" enable us to address the inherent complexity of development programs when there are many competing variables, environments are uncertain, the causal pathways to outcomes are unclear, and stakeholders bring diverse perspectives. Within the MOMENTUM suite of awards, many interventions will be complex. The Guide to Complexity-aware Monitoring Approaches for MOMENTUM Projects builds on the MOMENTUM Monitoring, Evaluation, and Learning (MEL) Framework. The guide helps MOMENTUM implementing partners, their counterparts at USAID, and other users compare and select from nine complexity-aware monitoring approaches to answer key questions on outcomes related to the project causal framework and factors that contribute to outcomes. It will help programs test critical assumptions and adjust program implementation promptly when needed. WHEN TO USE COMPLEXITY-AWARE MONITORING Complexity-aware monitoring approaches help answer several key questions that are often missing from traditional monitoring approaches or, because of the complexity of the situation, cannot be answered with traditional approaches. These include: • What outcomes, especially unintended outcomes, might be missing from the project causal framework? Moreover, innovations in projects or unstable environments could make project outcomes hard to predict. Methods to capture these unintended outcomes are useful, especially in complex projects. • What outcomes might yet emerge? When the time between project outputs and outcomes is long, complexity-aware monitoring can help identify interim milestones that mark progress towards outcomes that are yet to emerge fully. For example, if the intended outcome is to implement an intervention at scale in a country, progress markers might include the percentage of districts implementing the intervention. • How do stakeholders, including marginalized and underrepresented groups, perceive the project or intervention? Project implementers can use the perception of stakeholders (e.g., regional leadership, doctors and nurses, other staff, patients, and community members) regarding a quality improvement intervention in health facilities and its outcomes to validate findings from a quantitative review of routine service statistics. • What factors contributed to the observed outcomes? Project implementers can identify outcomes and then trace them back to the specific interventions that likely contributed to those outcomes. Building this association is especially relevant when external stakeholders make significant contributions. • What is happening in the broader context? Considering how stakeholders interact with each other, how information flows among them, and who influences them is relevant. This approach can help the project more efficiently target its efforts and monitor progress towards change.

Background
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.

This paper presents a collection of insights that may be helpful for funders who are interested in measuring the impact of innovation. It is built on the experience of experts from a wide range of agencies who came together in a Working Group on Measuring Impact facilitated by the Results for Development Institute under the International Development Innovation Alliance (IDIA). IDIA is an informal platform for knowledge exchange and collaboration among the following development innovation funders: Australian Aid Bill & Melinda Gates Foundation Global Afairs Canada Global Innovation Fund Grand Challenges Canada Results for Development Sida The Rockefeller Foundation UKAID — Department for International Development Unicef USAID World Bank Group When IDIA was created in early 2015, a key objective was for its members to begin promoting shared understandings around the complex practice of development innovation, and where possible collaboratively develop ‘common platforms for supporting innovation from idea to scale, shared learning and improved impact measurement’. The insights on measuring the impact of innovation presented here are one of a number of implementable, global public goods resulting from this process, and have been collated from the extensive learning and experience of development agencies both within and beyond IDIA. Together, they provide a broad architecture to help guide funders in navigating the long and complex process of impact measurement, while also ofering guidance to help innovators and partner organizations develop/enhance their own impact measurement approaches. These insights have been synthesized to create a highlevel architecture for measuring the impact of innovation that is built around a minimal set of ‘core’ indicators, with ‘lives saved and improved’ being the ultimate measures of success. These indicators are organized in terms of three key impact domains: (1) ‘Impact on Beneficiaries’, ‘Scale’ and ‘Sustainability’, with additional guidance on what to measure when assessing the potential impact of an innovation (the ‘Leading’ Indicators) and what to measure when assessing the actual, achieved impact (the ‘Outcome’ Indicators). Although it is hoped that this high-level architecture will facilitate closer alignment and collaboration among agencies involved in measuring the impact of development innovation, it is not designed to suggest that all innovation funders should therefore adopt exactly the same approach, or measuring only those indicators highlighted in this paper. Diferent agencies have their own missions and capacities that will shape the kind of data and impact they are looking for, and with a wide range of influencing factors1 in play within the broader social, political, cultural and economic environments in which innovations exist, it will also be necessary for funders to be flexible and agile in collecting diferent datasets at diferent times in order to understand why certain impacts are not achieved. T

Global Health Action is an international journal publishing research in the field of global health, addressing transnational health and policy issues.

Although experimental trials often identify optimal strategies for improving community health, transferring operational innovation from well‐funded research programs to resource‐constrained settings often languishes. Because research initiatives are based in institutions equipped with unique resources and staff capabilities, results are often dismissed by decisionmakers as irrelevant to large‐scale operations and national health policy. This article describes an initiative undertaken in Nkwanta District, Ghana, focusing on this problem. The Nkwanta District initiative is a critical link between the experimental study conducted in Navrongo, Ghana, and a national effort to scale up the innovations developed in that study. A 2002 Nkwanta district‐level survey provides the basis for assessing the likelihood that the Navrongo model is replicable elsewhere in Ghana. The effect of community‐based health planning and services exposure on family planning and safe‐motherhood indicators supports the hypothesis that Navrongo effects are transferable to impoverished rural settings elsewhere, confirming the need for strategies to bridge the gap between Navrongo evidence‐based innovation and national health‐sector reform.

Ghana's Community‐based Health Planning and Services (CHPS) initiative develops accessible healthcare with participatory community support, using strategies developed and tested by a project of the Navrongo Health Research Centre. In 1996, the project was expanded to a district‐wide four‐celled trial. In response to evidence that strategies could reduce fertility and childhood mortality, a replication project was launched to develop methods for scale‐up. Based on experience gained, CHPS scale‐up was launched in 2000. Although CHPS now reaches all of Ghana's districts, the pace of scale‐up within districts has been slow. In response, the Ministry of Health conducted a review of factors that constrain CHPS scale‐up and problems that detract from its original evidence‐based design. To resolve problems that were identified, a project was launched in 2010 to test means of accelerating CHPS scale‐up and expand its range of care. Known as the Ghana Essential Health Interventions Program (GEHIP), the project provided catalytic revenue to four treatment district managers for 3 years, in conjunction with implementation of strategies for comprehensive leadership development and community partnership. Monitoring systems were developed to gauge CHPS coverage time trends in all nine study districts. GEHIP successfully accelerated CHPS implementation, producing 100% of its targeted community coverage within 5 years of implementation. Coverage in comparison districts also improved. However, the rate of coverage and per cent of the population reached by CHPS in comparison districts was only half that of GEHIP districts. GEHIP success in completing CHPS coverage represents the initial stage of a national program for strengthening community health systems in Ghana. Copyright © 2015 John Wiley & Sons, Ltd.

Pilot approaches have been advocated as a means to reduce the risks associated with implementing complex health system reforms; however, there is a lack of guidance about when pilots may be appropriate or how they should be designed to respond to different contexts or objectives. This report presents the findings of a literature review and in-depth review of 17 health system reform pilots. The objectives of the review were to (i) synthesize lessons regarding conditions under which pilot projects are an appropriate means to further reform development, (ii) analyze how pilot projects and their monitoring and evaluation frameworks can best respond to alternative objectives and contexts, and (iii) develop guidance for the design of pilot projects. The study was hindered in achieving these objectives by the poor documentation on pilots; frequently documentation was only partial and was not consistently organized. Results support previous studies that suggest that frequently pilot objectives are not clear and that this is a major impediment to successful design and implementation. The study identifies a number of different factors that should be taken into account in determining the piloting approach. The most critical of these are the pilot objectives, and, related to the pilot objectives, the degree of consensus about the proposed policy reform. Other important factors that should be taken into account include country capacity, the size of the country and the degree of decentralization within the country. These factors should determine dimensions of the piloting approach including how centralized the pilot is, the type of monitoring and evaluation framework used, and the extent to which policymakers are involved in the pilot. The study finds that extensive donor involvement in a pilot is likely to shorten the time frame for the pilot, and that this can sometimes have problematic effects. While success of a pilot is often discussed in terms of whether or not the pilot was “rolled out,” the review shows that there are many other positive outcomes that pilots may achieve, and it argues that ultimately success should be judged against the objectives established for a particular pilot.

Evaluation of projects to improve health care in resource poor countries can provide ideas and inspiration to the often stalled efforts in healthcare organisations of wealthy nations Improvement is, I believe, an inborn human endeavour. My belief arises mostly from watching children. You cannot find a healthy child who does not try to jump higher or run faster. It takes no outside incentive. Children smile when they succeed; they smile to themselves. And so, it is my premise that almost all human organisations contain in their workforce an internal demand to improve their work. It saddens me how few organisations seem to know that, and fewer still act on it. Improvement is not forcing something; it is releasing something. Nevertheless, improving organisations is not easy. The barriers are many, and those barriers can produce a sense of helplessness and futility. Failing to improve, we feel unfortunate and wish that someone, somewhere, would give us that extra missing resource that we imagine would make change possible. “We want to make care better,” goes the complaint, “but they won\'t let us.” It might help us in the wealthy world to pause for a moment and reflect not on what we lack but on our good fortune. And the best way to do that is to look at those with less in their hands. In the past few years, I have been fortunate to do some work in resource poor countries, which have 90% of the people but only 10% of the world\'s wealth. My work in these settings has convinced me not only that it is possible to improve health care in resource poor settings but also that improvement may even be more feasible than it is in wealthy ones. Two remarkable projects in progress in the developing world show the tremendous resourcefulness, innovation, and potential for improvement in that resource constrained context, with potentially important lessons for caregivers in richer places.1

A sustained scaled up response to global public health challenges such as HIV/AIDS will require a functioning and efficient health system, based on the foundation of strong primary healthcare. Whilst this is necessary, it is not sufficient. Health promotion strategies need to be put into place to better engage and support families and communities in preventing disease, optimize caring, creating the demand for services and holding service providers to account. There will have to be a move away from the traditional model whereby the problem of HIV/TB/malaria is to be solved by merely increasing resources to a centralized bureaucracy that tries to increase the supply of services including health promotion messages. Development projects and programs that succeed are based on understanding of local practice and preferences, rather than on internationally ‘generalized models’ of how people or villages should behave and what they should want. This paper will first briefly review different approaches to scaling up health promotion interventions, some of the key obstacles in scaling up and then suggest some possible solutions with a focus on a human rights based approach. This approach changes the emphasis from the content of the message to the characteristics of a community\'s organisations and institutions. Scaling up occurs as a process of association between state actors and civil society that is planned strategically and involves a sharing of experience and a strong learning process among the association partners. A human rights-based approach can facilitate such an approach through developing a common vision, delineating roles and responsibility and facilitating communication channels for the most vulnerable. But this will require health development agencies to pursue a more overt political agenda. health promotion, HIV/AIDS, rights based approach

Background:
The scaling up of public health interventions has received greater attention in recent years; however, there remains paucity of systematic investigations of the scaling up processes. We aim to investigate the overall process, actors and contexts of polio immunization scaling up in Indonesia from 1988 until 2018.

Methods:
A mixed method study with sequential explanatory design was conducted. We carried out a quantitative survey of 323 actors involved in the polio program at national and sub-national levels, followed by Key InformantInterviews (KII)s. Document review was also carried out to construct a timeline of the polio eradication program with milestones. We carried out descriptive statistical analysis of quantitative data and thematic analysis of qualitative data.

Results:
The scaling up of polio immunization in Indonesia started as a vertical expansion approach led by the Ministryof Health within a centralized health system. The coverage of immunization increased dramatically from 5% in the earlier 80s to 67.5% in 1987; incremental increases followed until achieving Universal Child Immunization (UCI) in 1990and subsequently 95% coverage in 1995. Engagement of stakeholders and funding made the scaling up of polio immunization a priority. There was also substantial multi sector involvement, including institutions and communities. Local area monitoring (LAM) and integrated health posts (Posyandu) were key to the polio immunization implementation strategy. Challenges for scaling up during this centralized period included cold chain infrastructure and limited experience in carrying out mass campaigns. Scaling up during the decentralized era was slower due to expansion in the number of provinces and districts. Moreover, there were challenges such as the negative perception of immunization side-effects, staff turnover, and the unsmooth transition of centralization towards decentralization.

Conclusion:
Vertical scaling up of polio immunization program intervention was successful during the centralized era, with involvement of the president as a role model and the engine of multi sector actors. Posyandu (integrated health posts) played an important role, yet its revitalization after the reform-decentralization era has not been optimum.

Policy Points More rigorous methodologies and systematic approaches should be encouraged in the science of scaling. This will help researchers better determine the effectiveness of scaling, guide stakeholders in the scaling process, and ultimately increase the impacts of health innovations. The practice and the science of scaling need to expand worldwide to address complex health conditions such as noncommunicable and chronic diseases. Although most of the scaling experiences described in the literature are occurring in the Global South, most of the authors publishing on it are based in the Global North. As the science of scaling spreads across the world with the aim of reducing health inequities, it is also essential to address the power imbalance in how we do scaling research globally.

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.

Background: Scaling in health and social services (HSS) aims to increase the intended impact of proven effective interventions. Patient and public involvement (PPI) is critical for ensuring that scaling beneficiaries' interests are served. We aimed to identify PPI strategies and their characteristics in the science and practice of scaling in HSS.

Methods: In this scoping review, we included any scaling initiative in HSS that used PPI strategies and reported PPI methods and outcomes. We searched electronic databases (e.g., Medline) from inception to 5 February 2024, and grey literature (e.g., Google). Paired reviewers independently selected and extracted eligible reports. A narrative synthesis was performed and we used the PRISMA for Scoping Reviews and the Guidance for Reporting Involvement of Patients and the Public (GRIPP2).

Findings: We included 110 unique reports out of 24,579 records. In the past 5 years, the evidence on PPI in scaling has increased faster than in any previous period. We found 236 mutually nonexclusive PPI strategies among 120 scaling initiatives. Twenty-four initiatives did not target a specific country; but most of those that did so (n = 96) occurred in higher-income countries (n = 51). Community-based primary health care was the most frequent level of care (n = 103). Mostly, patients and the public were involved throughout all scaling phases (n = 46) and throughout the continuum of collaboration (n = 45); the most frequently reported ethical lens regarding the rationale for PPI was consequentialist-utilitarian (n = 96). Few papers reported PPI recruitment processes (n = 31) or incentives used (n = 18). PPI strategies occurred mostly in direct care (n = 88). Patient and public education was the PPI strategy most reported (n = 31), followed by population consultations (n = 30).

Conclusions: PPI in scaling is increasing in HSS. Further investigation is needed to better document the PPI experience in scaling and ensure that it occurs in a meaningful and equitable way.

This paper presents findings from research on the rate and impact of harmonization at the national level. It focuses on two country case studies; Tanzania and Uganda. The paper looks specifically at the effect of increased harmonization in these countries and whether it has led to any tangible improvements. It compares the different preferred modes for the delivery of donor aid and considers what information on health outcomes is currently available to measure performance. The paper also considers the suitability of various tools available for setting national sector targets. The question of resources needed to reach the health MDGs is also raised including costing, availability and the tensions between scaling up resources and macroeconomic stability. Finally, the paper outlines what bottlenecks currently exist to achieve the health MDGs in the countries studied. By way of illustration, the author has included quotations and opinions expressed by those interviewed throughout the course of the research. For reasons of confidentiality these quotations are un-attributed. 2. What has been the effect of increased harmonization? In Uganda and Tanzania, efforts towards greater harmonization through the Sector-Wide Approach (SWAp) as well as a stronger focus on budget support has increased the resources available to the health sector over the past five years. This in turn has led to improved health sector outputs in both countries, but not yet to measurable outcomes in all health millennium development goals (MDGs)1 .

The contribution of the District Clinical Specialist Teams (DCSTs) to improving maternal and child health outcomes in South Africa, through strengthening the four pillars of clinical governance, is reflected in innovative work presented at a ‘Promising Practices’ symposium and at various conferences. Of the 24 identified DCST innovations, 21% reflected the clinical effectiveness pillar, 17% clinical risk management, 41% staff development, and 21% user-related considerations. In order to ensure scale-up, the submitted best practices/ innovations were reviewed using the World Health Organization quality standards and ExpandNet parameters for likely scalability. Here we describe one case study from each pillar, illustrating the contribution of the innovations to improved patient outcomes. The development and scale-up of innovations needs to be institutionalised and must include effective support and action from the relevant health managers.

In 2006, the World Health Organization alerted the world to a shortfall of 4.3 million trained health workers globally, with the worst shortages in the poorest countries. As a direct result, millions die or are disabled every year and the Millennium Development Goals will not be achieved unless remedial action is taken. The Global Health Workforce Alliance (GHWA) was launched at the time of World Health Assembly Resolution 59.23 in 2006, to tackle these issues. In turn, GHWA set up task forces to address specific aspects of the problem such as health-worker education and training, migration and financing. Scaling Up, Saving Lives sets out the findings and recommendations of the Task Force for Scaling Up Education and Training for Health Workers. It complements the GHWA Agenda for Global Action. The Task Force has focused on countries with a health workforce crisis, particularly in Africa, and has found that current policies and plans are failing. The number of people being educated and trained is too small to make a difference. This is compounded by the fact that there is little international coordination of effort and, all too often, differential salary scales between public sector, international and private organizations, which drive up costs and lead to movement from the public sector, poor working conditions, and significant international migration of health workers. The situation needs to improve. Traditional approaches will not work – and thousands of people in the poorest countries in the world will continue to suffer unless we implement changes and a better way forward. Yet many leaders in developing countries know what needs to be done. Scaling Up, Saving Lives draws together evidence from countries such as Brazil, Ethiopia and India of what can and has been done practically and effectively to increase the education and training of health workers quickly and on a national scale, by national governments as well as education and training bodies. It sets out the critical success factors and effective strategies for scaling up education and training, based on a review of the evidence. The report also describes the economic background and the decisions that need to be made, and estimates that it will cost an additional US$2.6 billion a year to educate and train 1.5 million additional health workers just in Africa. This is a global problem. Scaling Up, Saving Lives sets out proposals for concerted action on a massive scale – with the international community fully supporting national leaders – to make sure that everyone has access to a suitably trained and motivated health worker as part of a functioning health system, and that: • national governments draw up 10-year scale-up plans and implement an immediate and huge increase in community- and mid-level health workers – trained, paid, supervised and able to refer on to more skilled workers – alongside the expansion of education and training for all groups of health workers;

Introduction: To make effective use of integrated initiatives and rapidly increase their wide-scale impact to benefit more people on a lasting basis, large-scale implementation is desirable. However, an understanding of what elements are related with successful implementation of integrated care initiatives on a larger scale remains largely unknown. WHO/ExpandNet argue that ‘’strategic planning for the expansion and institutionalization of successfully tested health systems innovations is essential’’[1]. Flexible, but intentional, scale-up strategies can help guide system changes [2].

This literature review aims to explore what scaling-up strategies for integrated care initiatives are described in literature, to describe to what extent these are theory-based, and how they match the framework for scaling-up, as defined by WHO [3].

Methods: PubMed Medline and Web of Science were consulted to collect data. A combination of three concepts are used as search strategy: 1 search terms describing “integrated care”; 2 search terms related to “scaling-up”; and 3 search terms related to “strategy”. Papers focusing on scaling-up and/or expansion of integrated care initiatives and reporting a strategy for expansion between January 2007 and December 2017 are identified. After the articles are retrieved, the framework for scaling-up, as defined by WHO, is used as a guide to extract the data. The guide includes the types of scaling-up i.e. vertical; horizontal; diversification; spontaneous, the steps for developing a scaling-up strategy for integrated care i.e. scalability; capacity of user organization; environment and planning actions; capacity of resource team; choices for vertical scaling-up; choices for horizontal scaling-up; role of diversification; actions for spontaneous scaling-up; and identification of next steps including the strategic choices made i.e. dissemination and advocacy; organizational process; costs/ resource mobilization; monitoring and evaluation.

Results: A number of 6,222 articles were identified in the two databases, after removing duplicates, a total of 5,568 potentially relevant articles have been reviewed based on title. After papers are included based on the title selection, the abstracts will be reviewed. Next, the included papers will be up for full text review. The reference lists of the full papers will also be checked to include additional relevant papers for final review. The data-analysis is ongoing at this moment Dec 2017.

Discussion: The framework for scaling-up does not specifically focus on scaling-up integrated care initiatives, however, since it is widely used and one of the few available comprehensive frameworks in scaling-up health interventions it has huge promise for the field of integrated care. We hypothesize to find a blend of types, strategic choices and steps for the scaling-up of integrated care.

Conclusion: This literature review will yield information around scaling-up strategies aimed at the transfer and scaling-up of successful integrated care initiatives. The insights on the usage of and potential gaps in scaling-up strategies will be useful to guide the further development, implementation and evaluation of scaling-up strategies.

Interest in “global health” among schools of medicine, public health, and other health disciplines in high-income countries (HIC) continues to rise. Persistent power imbalances, racism, and maintenance of colonialism/neocolonialism plague global health efforts, including global health scholarship. Scholarly projects conducted in low- and middle-income countries (LMIC) by trainees at these schools in HIC often exacerbate these problems. Drawing on published literature and shared experiences, we review key inequalities within each phase of research, from design through implementation and analysis/dissemination, and make concrete and practical recommendations to improve equity at each stage. Key problems facing global health scholarship include HIC-centric nature of global health organizations, paucity of funding directly available for LMIC investigators and trainees, misplaced emphasis on HIC selected issues rather than local solutions to local problems, the dominance of English language in the scientific literature, and exploitation of LMIC team members. Four key principles lie at the foundation of all our recommendations: 1) seek locally derived and relevant solutions to global health issues, 2) create paired collaborations between HIC and LMIC institutions at all levels of training, 3) provide funding for both HIC and LMIC team members, 4) assign clear roles and responsibilities to value, leverage, and share the strengths of all team members. When funding for global health research is predicated upon more ethical and equitable collaborations, the nature of global health collaborations will evolve to be more ethical and equitable. Therefore, we propose the Douala Equity Checklist as a 20-item tool HIC and LMIC institutions can use throughout the conduct of global health projects to ensure more equitable collaborations.

Contracting approaches have been used in various forms to improve the delivery of public health services in low- and middle-income countries. Cambodia has embarked on a public-sector reform that includes a model of internal contracting of health care through the Ministry of Health, supported by incentive payments for staff and facilities. Contracting for health care in Cambodia has evolved through three phases during 1997–2015, each with particular design features, arrangements, and structures; different levels of involvement of local and international stakeholders; and modifications based on evidence from operational research. Based on a review of published and gray literature and interviews with 29 local and international key informants, we identify national ownership, financial sustainability, and the need to strengthen service delivery institutions as the major forces that have shaped contracting in Cambodia, culminating in the move to internal contracting arrangements for public health care delivery. There remains a need to strengthen contracting governance arrangements. Keywords: Cambodia contracting health reform performance-based financing policy making

This paper reviews current strategies for scaling up successful interventions to meet the health-related needs of the poorest in developing countries. Findings show that all mechanisms for targeting the poorest suffer from elements of leakage, as well as weak institutional and governance structures. However, these problems are outweighed by the distributive benefits of some schemes. Demand-driven financing (involving the provision of resources to supply services for a distinct group) also has potential for reaching the poorest. However, parallel interventions on the supply side are needed to ensure quality is raised in addition to coverage. Several institutional obstacles to scaling-up small-scale interventions are identified. These include prohibitive or unsustainable costs, problems with scaling up targeting mechanisms (which often rely on local knowledge to target the poor effectively), and the risks of capture of decentralised resources by local elites. Effective collaboration between local constituencies and local governments or agencies is also harder to replicate on a regional or national scale. Key principles for successful scaling-up are identified as: a gradualist approach, a serious commitment to shifting power to the local level, a focus on ease of replication, and working within existing structures.

Because most women prefer professionally provided maternity care when they have access to it, and since the needed clinical interventions are well known, we discuss in their paper what is needed to move forward from apparent global stagnation in provision and use of maternal health care where maternal mortality is high. The main obstacles to the expansion of care are the dire scarcity of skilled providers and health-system infrastructure, substandard quality of care, and women\'s reluctance to use maternity care where there are high costs and poorly attuned services. To increase the supply of professional skilled birthing care, strategic decisions must be made in three areas: training, deployment, and retention of health workers. Based on results from simulations, teams of midwives and midwife assistants working in facilities could increase coverage of maternity care by up to 40% by 2015. Teams of providers are the efficient option, creating the possibility of scaling up as much as 10 times more quickly than would be the case with deployment of solo health workers in home deliveries with dedicated or multipurpose workers.

From 1994 to 2003, the government of Ghana investigated the child survival and fertility impacts of community-based primary care nurses and volunteer mobilisation efforts. This study, known as the Navrongo Project, demonstrated improved health outcomes and was scaled-up as the Community-based Health Planning and Services (CHPS) Initiative. Studies suggest that scaled-up CHPS services have not fully replicated the impact of the Project. This study investigates implementation challenges that could explain this atrophy by assembling the perspectives of health care managers that have experience with both the Project and CHPS. Data from in-depth interviews of health managers are analysed using deductive content analysis. Respondents exhibited a consistent vision of doorstep services with regard to the Project and CHPS. They shared the perspective that while scale-up has progressed slowly, it has expanded the range of services provided. Respondents felt, however, that the original emphasis on community involvement has atrophied with scale-up and that current operations are managed less rigorously than during the Project. Thus, while the expanded scope of CHPS has increased access to health care, the original focus on community engagement has faded. The original Project leadership strategy merits review for ways to integrate leadership development into scale-up activities. Keywords: community health; implementation research; scaling up.

Introduction In 2002, the Egypt Ministry of Health and Population faced the challenge of improving access to and quality of services in rural Upper Egypt in the face of low morale among health workers and managers. From 1992 to 2000, the Ministry, with donor support, had succeeded in reducing the nationwide maternal mortality rate by 52%. Nevertheless, a gap remained between urban and rural areas. Case description In 2002, the Ministry, with funding from the United States Agency for International Development and assistance from Management Sciences for Health, introduced a Leadership Development Programme (LDP) in Aswan Governorate. The programme aimed to improve health services in three districts by increasing managers\' ability to create high performing teams and lead them to achieve results. The programme introduced leadership and management practices and a methodology for identifying and addressing service delivery challenges. Ten teams of health workers participated. Discussion and evaluation In 2003, after participation in the LDP, the districts of Aswan, Daraw and Kom Ombo increased the number of new family planning visits by 36%, 68% and 20%, respectively. The number of prenatal and postpartum visits also rose. After the United States funding ended, local doctors and nurses scaled up the programme to 184 health care facilities (training more than 1000 health workers). From 2005 to 2007, the Leadership Development Programme participants in Aswan Governorate focused on reducing the maternal mortality rate as their annual goal. They reduced it from 85.0 per 100,000 live births to 35.5 per 100,000. The reduction in maternal mortality rate was much greater than in similar governorates in Egypt. Managers and teams across Aswan demonstrated their ability to scale up effective public health interventions though their increased commitment and ownership of service challenges. Conclusions When teams learn and apply empowering leadership and management practices, they can transform the way they work together and develop their own solutions to complex public health challenges. Committed health teams can use local resources to scale up effective public health interventions.

This article presents conceptual and methodological developments made in analyzing the scale up of results-based financing (RBF) as part of a multicountry research program supported by the Alliance for Health Policy and Systems Research. Following a brief overview of the research process, the article proposes a new five-dimensional conceptualization of scale-up (population coverage, service coverage, health system integration, cross-sectoral diffusion, and knowledge expansion) to capture various facets of RBF scale-up. It also presents how Walt and Gilson's health policy triangle framework was modified to identify the enablers and barriers to scale-up in the country case studies included in this research program. The article then puts forth a four-phase model of scale-up, including phases of generation, adoption, institutionalization, and expansion, developed for the purpose of this research program. The article concludes by providing some lessons learned on the use of the methods and theoretical frameworks developed for this multicountry research program.

CARE knows that communities are central to generating solutions to local challenges. When communities— rights holders—can exercise their rights and join local stakeholders, institutions and government—duty bearers—to participate in dialogue that can spur change and action—social accountability is in effect.

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.

The Peter C. Alderman Foundation (PCAF) and Ugandan government institutions initiated a public–private partnership (PPP) demonstrating the feasibility of delivering low cost, evidence-based mental health care to massively traumatized populations in northern Uganda. The PPP employed a systems approach to mental health care, wherein clinics could deliver uniform treatment that was locally adapted to each tribal culture. The PPP leveraged its pooled resources, raising the value of patient care to a level that none of the partners could provide by working alone. The PPP established metrics to assess the impact of therapy on war-affected people remaining in their own country after the cessation of hostilities. The ongoing prospective evaluation of PCAF program participants offers valuable information on the potential benefits of treating depression, post-traumatic stress disorder, and other mental, neurological, and substance use disorders in post-conflict low- and middle-income countries. The pressing, unmet mental health needs in the post-conflict regions of northern Uganda can be addressed through PPPs, with implications for programming in other post-conflict settings. Public health goals, and the strategies used to attain them, must be compatible with the cultural values of the recipient populations. We believe that this partnership provides a model for integrating mental health care into the primary care system in LMICs. Moreover, we believe it is replicable, and can be rolled out in other post-conflict countries facing similar public health problems.

This scaling up process has many dimensions to it, including technical, logistical, administrative, political, and social. While the search for biologically efficacious interventions, such as micronutrient supplements, has benefitted from the application of conventional biomedical science, the search for effective and sustainable strategies for scaling up will require the systematization and applications of contextual knowledge and experience. The Program Assessment Guide (PAG) provides a structured, participatory process for rigorously eliciting and systematizing contextual knowledge and experience to strengthen the design and delivery of interventions on a large scale. It can be used for the ex ante design of interventions and implementation systems or for assessing and strengthening the delivery of interventions in an on-going manner. It is intended to complement a number of other frameworks, tools, and guides, as referenced in this manual. The present version of the PAG is based on experience applying it in Kyrgyzstan and Bolivia, with further testing and refinement planned in the near future. The PAG is organized into modules that can be selected and sequenced to suit the context for a given country or organization. Some of its distinctive features are: it links individual interventions to broader interests and agendas in nutrition, health, food security and agriculture; it helps analyze delivery systems as social systems, to better identify and anticipate implementation bottlenecks and remedies; it encourages a specific focus on strategies to reach the most vulnerable; it provides a practical means for building a sound program theory, operations research agenda and M&E system from the bottom up; it clearly defines the roles and responsibilities of staff from national to community and households levels; it provides a means to stress-test contextual knowledge and experience, to improve rigor, question tacit assumptions and avoid group-think; it facilitates decisions to ensure follow-up of recommendations; and it builds national capacity and ownership for rigorous intervention planning, assessment, and improvement. The modular organization of the PAG is intended to help countries or organizations selectively use the modules and tools that could strengthen their current program planning and assessment procedures, thereby facilitating the more widespread adoption of whatever features may add value to their current practices. Of particular note are the Five Needs Tool and the Stress Testing Tool located in Module 5, which add rigor to most other approaches for intervention design and implementation. The PAG is best used in tandem with the WHO ExpandNet Guide and/or other tools that address the higher-level strategic issues in scaling up.

The Program Documentation Guide (PDG): helps country teams assess the current status of an intervention’s implementation, management and results, and streamline the reporting of these characteristics to multiple external partners. In its basic form it is applied in a one-day workshop with 4-10 participants who are most familiar with the intervention in question.

This briefing paper presents the results of a consortium-wide evaluation, 18 months into the PERFORM2Scale programme. It presents an overview of progress to date in each of the participating countries - Ghana, Malawi and Uganda.

Congress established the Center for Medicare and Medicaid Innovation (CMMI) to design, test, and spread innovative payment and service delivery models that either reduce spending without reducing the quality of care or improve the quality of care without increasing spending. CMMI sought to leverage these models to foster market innovation and accelerate the transformation of payment and care delivery to achieve the Triple Aim of better health, better care, and lower cost. This article provides a perspective on the design and execution of CMMI’s five initial models, the resulting outcomes and lessons, and how their core concepts evolved within and spread beyond CMMI. This experience yields three key insights that could inform future efforts by CMMI and public and private payers, including model designs and policy decisions. These insights center on the need for iterative testing and learning guided by market feedback, more realistic time frames to demonstrate impact on cost and quality, and greater integration of models.

Decision makers and the public are in need of information to guide their decisions about how to strengthen health services. This book pulls together available evidence concerning strategies to improve health services delivery in low- and middle-income countries (LMICs), using current methods to assemble a knowledge base and analyze the findings. It describes the results of reviews of such strategies, and how such strategies can produce gains for the poor. This type of information is intended to help decision makers in LMICs learn from others and from their own experiences, so that they may develop and implement strategies that will improve health services in their own setting. Local solutions on their own are unlikely to be easily scaled up. The institutional arrangements within which local service providers operate strongly influence their performance. These arrangements include the ways in which governments use their financial resources and regulatory powers and the roles of a variety of organizations that may include civil society organizations, nongovernmental organizations, as well as associations of professionals and other service providers and private companies. The arrangements also include the degree to which the health facilities are competitive or cooperative in their relationships with each other. The book provides some suggestions for what works and how to improve implementation, as the evidence does not hold up for “blueprint” planning. It finds that there are many ways that can succeed in improving health services. But not nearly enough attention has been paid to demonstrating how to improve services for the poor. Approaches that ask difficult questions, use information intelligently, and involve key stakeholders and institutions are critical to “learning and doing” practices that underlie successful implementation of health services

Two-thirds of the world's deaths in children younger than 5 years of age could be avoided by the implementation of known technologies.1 Scaling up evidence-based interventions could therefore accelerate reductions in mortality beyond secular trends driven by socioeconomic development.2, 3 UNICEF's large Accelerated Child Survival and Development (ACSD) programme in west Africa set out to scale up evidence-based interventions in 11 countries between 2001 and 2005, spending some US$27 million in the process. Three implementation packages, two preventive and one curative, were supported through health-facility-based, outreach, and community approaches. In The Lancet today, Jennifer Bryce and colleagues4 present a large careful assessment of the programme in three countries. Using a retrospective design, the investigators found that vertically delivered preventive interventions for expanded immunisation and antenatal care showed improved coverage over time in ACSD focus districts compared with results in comparison areas, whereas health-systems-dependent curative care for children with malaria and pneumonia did not. Mortality decreased over the study period, but decreases in ACSD focus districts were not greater than were those in comparison areas. What went wrong? Were the assumptions wrong? Was implementation inadequate? Or were the health systems just too under-resourced to deliver curative care, but could only manage vertical preventive campaigns? We are told supportive policies were not aligned, some drugs and supplies were not available, and community health workers were not given any incentives. However, we are not told why these shortcomings were present. Here is where the retrospective external assessment has limitations, since it does not sufficiently penetrate the “black box of implementation”. Yet questions of how to scale up delivery of evidence-based interventions within a health system are consistently scored as the top-priority research questions for child survival at national and global levels.

The global pandemic of physical inactivity requires a multisectoral, multidisciplinary public-health response. Scaling up interventions that are capable of increasing levels of physical activity in populations across the varying cultural, geographic, social, and economic contexts worldwide is challenging, but feasible. In this paper, we review the factors that could help to achieve this. We use a mixed-methods approach to comprehensively examine these factors, drawing on the best available evidence from both evidence-to-practice and practice-to-evidence methods. Policies to support active living across society are needed, particularly outside the health-care sector, as demonstrated by some of the successful examples of scale up identified in this paper. Researchers, research funders, and practitioners and policymakers in culture, education, health, leisure, planning, and transport, and civil society as a whole, all have a role. We should embrace the challenge of taking action to a higher level, aligning physical activity and health objectives with broader social, environmental, and sustainable development goals.

Why do some serious health issues--such as HIV/AIDS--get considerable attention and others--such as malaria and collapsing health systems--very little? Why and under what conditions do political leaders consider an issue worthy of sustained attention, and back up that attention with money and other resources? In this CGD Brief, visiting fellow Jeremy Shiffman discusses nine factors that influenced the degree to which national leaders in five countries made one public health issue--maternal mortality--a political priority. Pregnancy-related complications are the leading cause of mortality globally among adult women of reproductive age, with more than half a million deaths annually. But in some countries maternal health has become a priority and maternal deaths have fallen, while in other countries this has not yet occurred. Drawing on his comparison of these countries, Shiffman offers recommendations for public health priority-setting in developing countries. His bottom line: attaining public health goals is as much a political as it is a medical or technical challenge; success requires not only appropriate technical interventions but also effective political strategies.

There is renewed concern over the sustainability of disease control programmes, and re-emergence of policy recommendations to integrate programmes with general health systems. However, the conceptualization of this issue has remarkably received little critical attention. Additionally, the study of programmatic sustainability presents methodological challenges. In this article, we propose a conceptual framework to support analyses of sustainability of communicable disease programmes. Through this work, we also aim to clarify a link between notions of integration and sustainability. As a part of development of the conceptual framework, we conducted a systematic literature review of peer-reviewed literature on concepts, definitions, analytical approaches and empirical studies on sustainability in health systems. Identified conceptual proposals for analysis of sustainability in health systems lack an explicit conceptualization of what a health system is. Drawing upon theoretical concepts originating in sustainability sciences and our review here, we conceptualize a communicable disease programme as a component of a health system which is viewed as a complex adaptive system. We propose five programmatic characteristics that may explain a potential for sustainability: leadership, capacity, interactions (notions of integration), flexibility/adaptability and performance. Though integration of elements of a programme with other system components is important, its role in sustainability is context specific and difficult to predict. The proposed framework might serve as a basis for further empirical evaluations in understanding complex interplay between programmes and broader health systems in the development of sustainable responses to communicable diseases. Health system, communicable disease control programme, sustainability, integration, conceptual framework

The question of scale is often the first concern raised by donors and cooperating agencies when discussing the merits of community empowering approaches. Donors and cooperating agencies want to invest their limited resources in those projects with the greatest potential for widespread health improvement. While some may perceive communitybased approaches—specifically empowering approaches—as intensive efforts that reach relatively small populations, successful widespread impact is possible. “Taking Community Empowerment to Scale: Lessons from Three Successful Experiences” describes three USAID-funded programs that used community empowering approaches to achieve public health impact at scale in three different settings—Africa, Asia, and the Middle East. It also identifies the success factors common to all three programs. Each case study is a descriptive account of the program’s evolution, its stages, and the strategies used for successful scale-up. The brief review of current conceptualizations of empowerment and scale-up presented below illustrates the complexity of the issues at stake and sets the stage for the presentation of the case studies. The analyses of the case studies, however, relied on interviews with program staff and existing documentation to unveil— inductively and with as few preconceptions as possible—the lessons learned. Comparing the findings from these inductive analyses with current theoretical frameworks was beyond the scope of this report. We encourage readers to use both existing theoretical frameworks as well as lessons learned from practice to refine the design of community empowerment programs at scale.

The Learning Network is a forum for governments, funding partners, and social impact organizations to unpack the challenges of bringing innovations to scale and develop and implement practical approaches to remedy these challenges. The network seeks to catalyze a culture of collective impact and radical collaboration in how multisectoral stakeholders create enabling environments for innovation.

The IBP initiative, a WHO-based partnership of NGOs, civil society organizations, governments, academic institutions, and other implementing partners, promotes evidence-based global guidelines, tools, and other interventions for local application, and incorporates implementation experience and learning back into the global discourse.

Objective:
To identify the key factors that contribute to the successful scale-up of pilot projects, with emphasis on factors that are proven helpful in the successful scaling up of health interventions.

Methods:
Grey literature was searched at the library of the University of Kebangsaan, Malaysia, on database engines Google Scholar and Science Direct with specific key words to screen papers published from January 2001 to June 2016. They were reviewed to identify the key factors affecting scaling up of health-related pilot projects. Full-text articles were selected, and their reference lists were checked to look for relevant papers. They were short-listed and analysed using thematic approach.

Results:
Of the 47 articles initially screened, 14(29.78%) were shortlisted. Thematic analysis of the selected articles suggested several key factors contributed to the successful scale-up of pilot projects. These factors included evidence-based and effective intervention, community readiness, government support, stakeholders' engagement, and monitoring and supervision.
Conclusions:
To maximise health coverage in developing and low middle-income countries, scaling up of health interventions on a large scale is essential to improve the health and wellbeing of people. The identified key factors should be considered while planning the scale-up of any health project.

Implementation research is important in global health because it addresses the challenges of the know–do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.

Background
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.

Two trends are slowly reshaping the international development system. They hold the promise of democratizing and reforming the international system and the international practice of development. One is the process of 'scaling up', in which grassroots organisations and local nongovernmental organisations (NGOS) seek to expand their impact and move beyond the local level. In doing so, they are becoming players, often reluctantly, at the national and international levels. 'Scaling down' refers to processes whereby international organisations (Ios) change their structures and modes of functioning to allow for meaningful interaction and cooperation with grassroots organisations and NGOS. This essay analyses the nature of scaling up and scaling down, how exten- sively they have taken place, how that has been done, and the risks and difficulties associated with these processes. It will do so largely from the point of view of Third World NGOS and within the context of development. Part one briefly defines terms. Part two deals with scaling up the grass roots. It first presents a typology of scaling up, and then discusses the reasons that motivate NGOS and ios to collaborate. Afterwards, it puts forward a hierarchy of NGO participation in international regime creation and implementation. Finally, it discusses some of the dangers and risks that NGOS face when scaling up. Part three deals with scaling down the summit. It first presents various arguments in favour of scaling down the summit and then analyses how much such processes of scaling down have occurred.

How can we ensure that cutting edge scientific results enhance sustainability and lead to concrete improvements in peoples' lives? To make an impact, scientific knowledge has to be embedded in products and organizations that meet three criteria: 1. Financial, operational, and environmental sustainability; 2. Accessibility to the billions of people with low income rather than serving only the economic elites; 3. Deployed at scale to improve the lives of hundreds of millions of people in dozens of countries in thousands of communities around the world. The panelists will discuss why this daunting task is eminently worth pursuing, but will require some changes to business-as-usual procedures in the scientific community and in within industry.

Background
The availability of medicines in public health facilities in Tanzania is problematic. Medicines shortages are often caused by unavailability at Medical Stores Department, the national supplier for public health facilities. During such stock-outs, districts may purchase from private suppliers. However, this procedure is intransparent, bureaucratic and uneconomic.

Objectives
To complement the national supply chain in case of stock-outs with a simplified, transparent and efficient procurement procedure based on a public-private partnership approach with a prime vendor at the regional level. To develop a successful pilot of a Prime Vendor system with the potential for national scale-up.

Methods
A public-private partnership was established engaging one private sector pharmaceutical supplier as the Prime Vendor to provide the complementary medicines needed by public health facilities in Tanzania. The Dodoma pilot region endorsed the concept involving the private sector, and procedures to procure complementary supplies from a single vendor in a pooled regional contract were developed. A supplier was tendered and contracted based on Good Procurement Practice. Pilot implementation was guided by Standard Operating Procedures, and closely monitored with performance indicators. A 12-step approach for national implementation was applied including cascade training from national to facility level. Each selected vendor signed a contract with the respective regional authority.

Results
In the pilot region, tracer medicines availability increased from 69% in 2014 to 94% in 2018. Prime vendor supplies are of assured quality and average prices are comparable to prices of Medical Stores Department. Procurement procedures are simplified, shortened, standardized, transparent and well-governed. Procurement capacity was enhanced at all levels of the health system. Proven successful, the Prime Vendor system pilot was rolled-out nationally, on government request, to all 26 regions of mainland Tanzania, covering 185 councils and 5381 health facilities.

Conclusion
The Prime Vendor system complements regular government supply through a regional contract approach. It is anchored in the structures of the regional health administration and in the decentralisation policy of the country. This partnership with the private sector facilitates procurement of additional supplies within a culture of transparency and accountability. Regional leadership, convincing pilot results and policy dialogue have led to national roll-out. Transferring this smaller-scale supply chain intervention to other regions requires country ownership and support for sustainable operations.

Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability (effects being sustained over time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness). We also argue that agreeing a framework for design and evaluation of HSS is urgent. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spillover effects and their contribution to meeting overarching healthsystem process goals. We make some initial suggestions about such goals, to reflect the features that characterise a “strong health system.” We highlight that current findings on “what works” are just indicative, given the limitations and biases in what has been studied and how, and argue that there is need to rethink evaluation methods for HSS beyond finite interventions and narrow outcomes. Clearer concepts, frameworks, and methods can support more coherent HSS investment. KEYWORDS health system strengthening, low- and middle-income countries

Civic, cultural, political, economic, social rights. Discrimination on the basis of sex. Rights-based approach. Health-related human rights. Gender equality.

Given Senegal's limited resources, the country receives substantial support from externally funded partner organizations to provide family planning and maternal and child health services. These organizations often take a strong and sometimes independent role in implementing interventions with their own structures and personnel, thereby bypassing the government district health system. This article presents findings from the Initiative Sénégalaise de Santé Urbaine (ISSU) (Senegal Urban Health Initiative) that assessed in 2 districts, Diamniadio and Rufisque, the extent to which it was feasible to create stronger government ownership and leadership in implementing a simplified package of family planning interventions from among those previously tested in other districts. The simplified package consisted of both supply- and demand-side interventions, introduced in October 2014 and concluding at the end of 2015. The interventions included ensuring adequate human resources and contraceptive supplies, contraceptive technology updates for providers, special free family planning service days to bring services closer to where people live, family planning integration into other routine services, household visits for family planning education, religious sermons to clarify Islam\\\\\\\'s position on family planning, and radio broadcasts. District leadership in Diamniadio and Rufisque were actively involved in guiding and implementing interventions, and they also contributed some of their own resources to the project. However, reliance on external funding continued because district budgets were extremely limited. Monitoring data on the number of contraceptive methods provided by district facilities supported by a sister project, the Informed Push Model project, indicate overall improvement in contraceptive provision during the intervention period. In Diamniadio, contraceptive provision increased by 43% between the 6-month period prior to the ISSU interventions (November 2013 through April 2014) and a 6-month intervention period (November 2014 through April 2015), from about 8,000 units to nearly 12,000 units. In Rufisque, contraceptive provision increased by 30%, from more than 17,000 units to more than 22,000 units. Couple-years of protection provided in Diamniadio increased by 82% and in Rufisque by 56%. The experience in these 2 districts in Senegal suggests that it is feasible for districts to play a leadership role in implementing family planning services and mobilizing some of their own resources and that international projects can facilitate capacity building and sustainability within public-sector systems.

Objective: As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC.

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.

At the 2012 London Summit on Family Planning, and in a subsequent eight-year scale up plan, Zambia made a commitment to increase its contraceptive prevalence rate (CPR) to 58 percent by 2020, through a mix of policy and programmatic approaches. In addition to increasing domestic funding and partnerships with donors and strengthening the supply chain for commodities, Zambia pledged to expand method mix and increase access to family planning (FP), particularly for underserved populations, through the use of community-based distributors (CBDs) to increase demand among women, men and communities. With a mCPR of 45 percent in 2014, the country needs to accelerate scale up in order to meet the contraceptive needs of women and couples and to achieve its goal of 58 percent mCPR. A number of supply-side barriers limit family planning provision, particularly of LARCs, including a shortage of trained staff and lack of needed equipment, commodities and consumables (MCDMCH, 2013). At the health center level, stock outs are more frequent than at higher levels, due to inadequate transport of supplies and delays in submitting requisition orders at facility and district levels. Additionally, although FP is free at public sector facilities, the limited method mix in the public sector constrains contraceptive choice, and price remains a barrier in the private sector. Distance is often a barrier for those living in rural areas, especially during the rainy season when travel time to a health facility averages two hours. Scheduling of services can also serve as a barrier for FP access, especially when the hours are limited and services are not coordinated with the provision of other related services that women attend. Lastly, inadequate infrastructure may limit a woman’s privacy and comfort in accessing FP services. Demand-side barriers to the adoption of FP also inhibit use, including actual or feared partner/spousal disapproval, social stigma, myths, rumors and misinformation about FP generally and about specific methods, fear of side effects, and health concerns. Some methods, notably LARCs other than injectables, suffer from negative myths and false beliefs. For example, some believe that implants and IUDs can travel around the body and become lodged in the brain, the heart, or a growing fetus, or that fertility will not return after LARC removal. Some health providers, too, reportedly share these negative beliefs and then act to deter client’s interest in contraceptive use. Adolescent fertility in Zambia is a concern. The country has one of the highest adolescent fertility rates in sub-Saharan Africa (CSO et al., 2014). 29 percent of teenage girls ages 15-19 have begun child bearing. Limited access to FP, particularly among young women, is evident in the large number of young women receiving post-abortion care services in Zambia. For instance, in 2010, 90 percent of the 90,000 women who received post-abortion care in Zambia were under the age of 20 (MCDMCH, 2013).

SUFP focused on several important aspects of decentralizing and integrating FP service delivery into the government health system at district, facility, and community levels, with an emphasis on reaching poor and 2 | RESEARCH REPORT under-served women and adolescents. These aspects included capacity building, infrastructure strengthening, behavior change communication (BCC), contraceptive security, policy and advocacy in support of an enabling environment for reproductive health (RH) and FP, supply chain management, and strengthening management information systems. SUFP also trained and mentored public health professionals to deliver comprehensive FP counseling. Additionally, SUFP provided support to the district with service coordination and with funds for outreach and supervision when necessary. It should be noted that SUFP did not directly provide family planning services, but aimed at improving demand and supply for services provided by the Government. An innovative element of the project’s initial package of scaling-up activities was a camping approach, which involved a team of SUFP facilitators and MCDMCH health facility staff who “camped” in targeted areas within the district for two weeks each, with an area typically being a health center and its catchment population. During the camping visits the MCHMCH team provided FP services, with a particular focus on long-acting, reversible methods (LARCs), and disseminated intensive IEC and BCC messages to communities, with a special focus on adolescents. As the project was rolled out the camping process was reportedly implemented more by the MCDMCH staff with less support from the project. The camping approach was intended to create more demand for services and to strengthen the ability of the health facility staff to conduct outreach more regularly.

Background:
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

The 1994 International Conference on Population and Development in Cairo codified views long advocated by women’s health activists the world over. The conference marked a turning point in the history of the population field—one that brought reproductive health and women’s rights to the forefront of the international population agenda. The 22 case studies in this book document changes in practice in reproductive health and family planning programs within 18 countries. The case studies demonstrate the important strides that were made in the years following the conference and point to many challenges that remain. The abolition or modification of population policies that are inimical to women\\\'s freedom of choice, integration and expansion of reproductive health services to meet a broader range of women\\\'s needs, efforts to address sexuality, gender-based power, and partner relations in the service-delivery context, and the social and economic causes of women\\\'s reproductive health problems are discussed.

Contraceptive implants offer promising opportunities for addressing the high and growing unmet need for modern contraceptives in sub-Saharan Africa. Marie Stopes International (MSI) offers implants as one of many family planning options. Between 2008 and 2012, MSI scaled up voluntary access to implants in 15 sub-Saharan African countries, from 80,041 implants in 2008 to 754,329 implants in 2012. This 9-fold increase amounted to more than 1.7 million implants delivered cumulatively over the 5-year period. High levels of client satisfaction were attained alongside service provision scale up by using existing MSI service delivery channels—mobile outreach, social franchising, and clinics—to implement strategies that broadened access for underserved clients and maintained service quality. Use of adaptive and context-specific service delivery models and attention to key operational components, including sufficient numbers of trained providers, strong supply chains, diverse financing mechanisms, and implant removal services, underpinned our service delivery efforts. Accounting for 70% of the implants delivered by MSI in 2012, mobile outreach services through dedicated MSI provider teams played a central role in scale-up efforts, fueled in part by the provision of free or heavily subsidized services. Social franchising also demonstrated promise for future program growth, along with MSI clinics. Continued high growth in implant provision between 2011 and 2012 in all sub-Saharan African countries indicates the region\'s capacity for further service delivery expansion. Meeting the expected rising demand for implants and ensuring long-term sustainable access to the method, as part of a comprehensive method mix, will require continued use of appropriate service delivery models, effective operations, and ongoing collaboration between the private, public, and nongovernmental sectors. MSI\'s experience can be instructive for future efforts to ensure contraceptive access and choice in sub-Saharan Africa, especially as the global health community works to achieve its Family Planning 2020 (FP2020) commitments to expand family planning access to 120 million new users.

In 2017, the Ministry of Health and Public Hygiene (MSHP) of Côte d’Ivoire initiated the institutionalization of immediate postpartum family planning (IPPFP) following promising results of a first ever IPPFP intervention implemented at the Treichville University Hospital.

Social marketing brand of private health services in Kenya Antenatal care AIDS, Population and Health Integrated Assistance Program (Kenya) Accredited Social Health Activist (India) Anganwadi Center (India) Anganwadi Workers (India) Bill and Melinda Gates Foundation India Solutions for Sustainable Development Centre for Communications Programs Nigeria Community Health Extension Worker Community Health Worker Chief Medical Officer (India) Contraceptive Prevalence Rate Development Communications Network: An NGO partner of NURHI Department for International Development District Health Management Team (Kenya) Demographic Health Survey Kenya Department of Health Information System II Depot medroxyprogesterone acetate (DepoProvera) Directorate of Reproductive Health and Child Survival (Senegal) District Women’s Hospital (India) Emergency contraception Nigeria Federal Ministry of Health Federation of Obstetric and Gynaecological Societies of India Family Planning Family Planning Providers Network of Nigeria Foundation for Research in Health Systems (India) Fixed Service Day (India) GI Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins University Human immunodeficiency virus infection and acquired immune deficiency syndrome Hindustan Latex Family Planning Promotion Trust (India) Integrated Child Development Services (India) Information, Education and Communication Interpersonal Communication Informed Push Model (Senegal) Senegal Urban Reproductive Health Initiative Intrauterine Device Johns Hopkins Program for International Education in Gynecology and Obstetrics Johns Hopkins University Center for Communications Programs Kenya Medical Supplies Authority Kilometer Long-acting reversible contraception Local Government Area (Nigeria) Modern Contraceptive Prevalence Rate Marginal effect Management Information System Measurement, Learning and Evaluation Maternal, Newborn and Child Health Ministry of Health Ministry of Health and Family Welfare (India) Marie Stopes International Marie Stopes International Kenya Marie Stopes International Organization Nigeria National AIDS Control Organization (India) National Council for Population and Development (Kenya) Non governmental Organization National Health Mission (India) Nigerian Urban Reproductive Health Initiative Nigerian Urban Reproductive Health Initiative, Phase 2 Oral Contraceptives Paquet Minimum to Maximize District Leadership and Performance in Senegal Program Implementation Plan (India) Performance Monitoring and Accountability 2020 Patent Medical Vendor (Nigeria) Postpartum IUD Private Public Partnership Population Services International Parivar Seva Sanstha, NGO (India) Reproductive Health Service Delivery Point Sexual Reproductive Health TA Technical Assistance The Challenge Initiative Technical Support Unit (India) India Urban Reproductive Health Initiative United Nations Population Fund Uttar Pradesh, India Urban Reproductive Health Initiative United States Agency for International Development Voluntary Counseling and Testing

Strong health systems play a crucial role in making services accessible and affordable; and scaling up health innovations intrinsically requires efforts to strengthen health systems. Georgetown University’s Institute for Reproductive Health (IRH) is engaging in a strategic process to scale up two family planning (FP) innovations—the Standard Days Method® (SDM) and the Lactational Amenorrhea Method (LAM)—into existing programs in select countries.i In this brief, we describe how through scaling up these Fertility Awareness-based Methods (FAM), IRH is strengthening broader health systems.

Emergency contraception (EC) has been around for decades, but the first serious introduction and scale-up efforts started in the mid 1990’s. This paper reviews programmatic experiences that sought to expand access to emergency contraceptive pills (ECP) in Africa, Asia and Latin America over the last decade. This multiregional review identifies the individual phases of the introductory processes as well as facilitators and barriers to successful scale-up of ECP service provision. Characteristics of successful projects included conduction of multi-sector diagnostic assessments; careful consideration of legal and policy issues; collaborative advocacy and technical assistance for inclusion in public family planning programs by national and international institutions; as well as attention to programmatic areas such as capacity-building, supply-chain and awareness-raising. Lessons learned from varied developing country experiences are discussed as is the need for increased attention to evaluating and disseminating project results. Emergency contraception, advocacy, service provision, communications activities, legal and policy issues,

Contraceptive prevalence rate among the currently married women rose from 7.7 percent to 58 percent in Bangladesh over the last three decades .The unmet need for family planning services however, has remained around 15 percent during the last 10 years (NIPORT et al. 2000). Further, each year about one-third of the four million pregnancies in Bangladesh are unplanned or unwanted (NIPORT et al. 2004). Beside non-use of contraceptive, error in methods used, are thought to account for the overwhelming majority of unintended pregnancies among contraceptives users, particularly for the developing world including Bangladesh (Haishan et al. 1999). To give women a last chance to save themselves from unwanted pregnancies, in 2001 the Government of Bangladesh (GOB) decided to introduce Emergency Contraceptive Pills in the National Family Planning Program. It was also decided to provide ECP service through grass-root workers, NGOs and community-based workers. The Government\'s decisions were based on findings from an operations research (OR) undertook by the FRONTIERS Program of Population Council in collaboration with the Directorate General of Family Planning (DGFP), Pathfinder International and JSI in Bangladesh. The study showed big unmet need of ECP and women\'s willingness to use it as a back up support to the existing contraceptive methods. It also revealed no significant variation in the level of knowledge gain, retention of knowledge and provision of services of ECP between physicians and the service providers after the training. The study also demonstrated service provider\'s ability to retain enough knowledge and skills on ECP after four months of training (Khan et al. 2005). 2004, ECP scale up was introduced in the rest of the country, covering the remaining 47 districts and about 89 million population.

During the 1970s and 1980s under the Ceausescu dictatorship, family planning and abortions were highly restricted in Romania as the government pursued a rigidly enforced pronatalist policy. After the fall of the regime in 1989, such policies were reversed. Desire for small family size resulted in low fertility rates, but modern contraceptives were not readily available or affordable, and there was a dramatic lack of access to family planning (FP) services for all of Romania but especially in rural areas and for the poor. As in many Central and Eastern European countries, abortion became the most prevalent method of birth spacing and fertility control. In the late 1990s, the ongoing process of Romanian health reform introduced the family doctor (a general practitioner) as the gatekeeper for the health system, and began the shift from a vertical model based on medical specialists to a primary health care (PHC) system. The continuous development of the private sector in the mid-1990s, together with the government network of FP clinics in urban areas (210 urban FP clinics around the country), led to an improvement in access to modern contraceptives for the urban population. But the incidence of unintended pregnancy, the abortion rate, and maternal mortality due to abortion remained high compared to most countries in Europe, and access to modern contraceptives continued to be extremely limited, particularly in rural areas. By 1999, the new category of health providers, family doctors, were offering a considerable range of services, but not family planning, due to lack of training and the absence of enabling regulations and norms to provide this new service. In 1999, a USAID-funded project implemented family planning as an integrated component of primary care services in 36 primary health care units in 3 districts. Under the project, family doctors provided FP services and dispensed free contraceptives. The success of this pilot project laid the groundwork for national scale up, which was implemented by the Romanian Family Why It Matters In the 1990s access to family planning was extremely limited in rural areas of Romania and abortion was the most widespread method of birth control. Under the JSI-led Romanian Family Health Initiative (RFHI) integrated family planning coverage has expanded nationwide to over 2000 rural communities. The central and district governments manage the program and supervise service providers, an efficient logistics system is procuring and distributing contraceptives, and innovative behavior change campaigns and IEC materials have led to more informed choice-making. Surveys show that rural modern contraceptive use increased from 21% in 1999 to 33% in 2004, while rural abortion declined from 2.4 to 1.1 in the same period. to expand and improve FP and other reproductive health (RH) services, and to work at the policy and service provision levels to ensure that FP/RH services are fully integrated into the framework of Romanian health reform.

This article is based on the ten-year experience of an operations research project in Bangladesh. It assesses how, and under what circumstances, research-based advice and results of pilot projects contribute to change in large-scale public programs. It discusses project research on issues facing the national family planning program: recruitment and training of field-workers; delivery of injectable contraceptives; management information; field-workers\' use of service registers; field supervision; satellite clinics; and contraceptive user fees. These issues are used to illustrate the advantages and disadvantages of a long-term institutionalized project, and to describe the diversity of means for communication with policymakers. The analysis shows that research, policy decision, and implementation can occur in any sequence. Policy advice that disrupts long-standing power relationships and organizational culture takes a great deal of effort to implement. Operations research can produce useful changes in organizational behavior, even when large-scale problems remain.

Previous analyses have emphasised the crucial importance of family planning to achieve a range of health and other development objectives in developing countries. This Viewpoint focuses on the successful implementation of services in Ethiopia, Africa\'s second most populous country. Ethiopia\'s encouraging experience could challenge the widely held assumption that a decline in fertility must be preceded by sweeping economic and educational advancement, and offers other useful policy and programmatic lessons for other low-income countries, especially in sub-Saharan Africa. In July, 2012, The Bill & Melinda Gates Foundation and the UK Department for International Development convened a historic London Summit On Family Planning to revitalise efforts to expand family planning services in developing countries. The urgency of realising this expansion has become more widely acknowledged as the adoption of family planning has shown to generate important public health outcomes, such as reductions in maternal and child mortality and abortions.Analysis also suggests that family planning is indispensable for achieving a range of other crucial development objectives, including several other Millennium Development Goals (MDGs) that address economic development, women\'s empowerment and education, and environmental protection. Nowhere are these services more needed than in sub-Saharan Africa, where in many countries contraceptive use continues to stagnate at about 10% and typically at least a quarter of women report wanting to prevent or delay pregnancy but do not use modern family planning methods.

There is no guarantee that a successful pilot program introducing a reproductive health innovation can also be expanded successfully to the national or regional level, because the scaling-up process is complex and multilayered. This article describes how a successful pilot program to integrate the Standard Days Method (SDM) of family planning into existing Ministry of Health services was scaled up nationally in Rwanda. Much of the success of the scale-up effort was due to systematic use of monitoring and evaluation (M&E) data from several sources to make midcourse corrections. Four lessons learned illustrate this crucially important approach. First, ongoing M&E data showed that provider training protocols and client materials that worked in the pilot phase did not work at scale; therefore, we simplified these materials to support integration into the national program. Second, triangulation of ongoing monitoring data with national health facility and population-based surveys revealed serious problems in supply chain mechanisms that affected SDM (and the accompanying CycleBeads client tool) availability and use; new procedures for ordering supplies and monitoring stockouts were instituted at the facility level. Third, supervision reports and special studies revealed that providers were imposing unnecessary medical barriers to SDM use; refresher training and revised supervision protocols improved provider practices. Finally, informal environmental scans, stakeholder interviews, and key events timelines identified shifting political and health policy environments that influenced scale-up outcomes; ongoing advocacy efforts are addressing these issues. The SDM scale-up experience in Rwanda confirms the importance of monitoring and evaluating programmatic efforts continuously, using a variety of data sources, to improve program outcomes.

This summary document presents conclusions from a six-year, five-country initiative conducted by the Institute for Reproductive Health (IRH) and its many in-country partners to scale up Standard Days Method® (SDM) of family planning. SDM, briefly described in the text box at right, is itself not the topic of this document.1 Rather, the SDM scale-up experience is the source of the contributions that IRH makes to global knowledge of the process of scaling up tested health service innovations. Scale-up is the deliberate set of efforts to increase the impact of health innovations whose merit has been established in pilot or experimental studies, to benefit more people and to foster policy and program support on a lasting basis. 2 This definition clarifies that scaleup does not happen spontaneously, and that if it is to be sustained, it must encompass not only expanded availability of an innovation, but also its institutionalization in policies and programs. From 2000, when it developed SDM, through 2006, IRH conducted clinical trials, pilot introductions, operations research, and impact studies in diverse settings around the globe. Results of these studies suggested that SDM merited scale-up for a number of reasons (see box). In 2007, with USAID support for adding a simple, modern, natural family planning (NFP) method to national programs, IRH shifted its attention to planning and implementing a multi-site program of SDM at scale. The World Health Organization’s (WHO) ExpandNet framework3 for scale-up was selected to guide IRH’s strategy to scale up SDM (see description on page four). With this framework as a guide, IRH embarked on a program that simultaneously (a) took the method to scale in five countries, thereby bringing an effective and attractive new method within reach of millions; and (b) conducted a prospective multi-site case study to document, assess, and guide the scaleup process, thereby enriching the global body of knowledge on how to expand and sustain worthy health innovations.

Introduction:
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.

This paper describes how the Urban Reproductive Health Initiative in Kenya, the Tupange Project (2010-2015), successfully applied the ExpandNet approach to sustainably scale up family planning interventions, first in Machakos and Kakamega, and subsequently also in its three core cities, Nairobi, Kisumu and Mombasa. This new focus meant shifting from a “project” to a “program” approach, which required paying attention to government leadership and ownership, limiting external inputs, institutionalizing interventions in existing structures and emphasizing sustainability. The paper also highlights the project’s efforts to prepare for the future scale up of Tupange’s interventions in other counties to support continuing and improved access to family planning services in the new context of devolution (decentralization) in Kenya. © 2015 Reproductive Health Matters. Published by Elsevier BV. All rights reserved. Keywords: Family planning, scaling up, sustainable scale up, Kenya, Tupange, urban poor, devolution, decentralization, project approach, program approach, Urban Reproductive Health Initiative, ExpandNet

This case study presents service monitoring data and programmatic lessons from scaling up Uganda\'s community‐based distribution of depot medroxyprogesterone acetate (DMPA, marketed as Depo‐Provera) to the public sector in two districts. We describe the process and identify implementation opportunities and challenges, including modifications to the service model. Analysis of monitoring data indicates that the number of women initiating DMPA with a community health worker (CHW) was 56 percent higher than the number of new DMPA acceptors served by clinics. Including continuing DMPA users, about three of every four DMPA clients chose CHWs as their service delivery point. CHW provision appears to be the preferred method of delivery for new DMPA users in this study, and may appeal even more to continuing clients. Lessons from scaling up in Uganda\'s public sector include recognizing the needs for ongoing assessment of support, a process to gain community “ownership,” and spontaneous innovations to supplement CHW supervision.

Expanding access to family planning and addressing unmet needs for contraception are key goals for improving reproductive health. Poor access to family planning is associated with unintended pregnancies and poorer maternal and newborn outcomes, including abortion-related morbidity and mortality1. Addressing unmet need helps increase contraceptive use and reduces unintended pregnancies, leading to improved health outcomes and broad social and economic benefits for women, their families and societies. Unmet need reflects gaps in both demand and supply of contraceptive services. The challenges posed are greater in low- and middle-income countries (LMICs), especially in sub-Saharan Africa (SSA)2. Progress to reduce unmet need remains slow and more effective ways are required to expand family planning care on a larger scale.

Background
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.

In Kinshasa, Democratic Republic of the Congo (DRC), modern contraceptive prevalence is low by international standards: 29.6% as of 2020. A 2015 pilot study demonstrated the feasibility and acceptability of using medical and nursing students to administer DMPA-SC (the subcutaneous injection) among other methods at the community level. The more far-reaching discovery was the potential of clinically trained students to increase access to low-cost contraception in the short-run, while improving the quality of service delivery for future generations of healthcare providers. Scale-up involved integrating the family planning curriculum into the training of nursing students, including classroom instruction in contraceptive technology and service delivery, coupled with a year-long field practicum in which students offered a range of contraceptive methods during intermittent outreach events, door-to-door distribution or sales from their homes. Starting in 2015, a multi-agency team consisting of an international non-governmental organizations (NGO), several Ministry of Health directorates and a local NGO used the ExpandNet/WHO framework to guide this scale-up. This article details the nine steps in the scale-up process. It presents results on increases in contraceptive uptake, feedback from participating nursing school personnel and the employment experience of the graduates from this programme. Between 2015 and 2019, the family planning curriculum was incorporated into 30.8% of the 477 nursing schools in 7 of the 26 provinces in the DRC. Students delivered 461 769 couple-years of protection (the key output indicator for family planning programmes). Nursing school personnel were strongly favourable to the approach, although they needed continued support to adequately implement a set of additional interventions related to the service delivery components of the new training approach. Post-graduation, only 40.1% of graduates had paid employment (reflecting the staggering unemployment in the DRC); among those, over 90% used their family planning training in their work. We describe the multiple challenges faced during the scale-up process and in planning for expansion to additional schools. Keywords: Democratic Republic of the Congo (DRC); Scale-up; community-based services; contraception; family planning; nursing students.

The Republic of Benin faces high maternal, newborn, and child mortality; low modern contraceptive use; and a critical shortage of health workers. In 2013, the Government of Benin made 3 reproductive health commitments to improve national health indicators, including expanding provision of family planning services at the community level through task sharing. Since 2016, the Advancing Partners & Communities (APC) project has been helping the Benin Ministry of Health (MOH) provide subcutaneous depot medroxyprogesterone acetate (DMPA-SC; brand name Sayana Press) through facility-based health care providers and community health workers known as relais communautaires (RCs). DMPA-SC is an easy-to-administer, discreet injectable contraceptive that provides 3 months of protection from pregnancy. Beginning in May 2017, the government introduced DMPA-SC through a phased approach in 10 health zones, which encompassed 149 health centers and 614 villages. Between June 2017 and June 2018, the MOH and APC trained 278 facility-based providers and 917 RCs to provide DMPA-SC, and nearly 11,000 doses were subsequently administered to 7,997 women at facilities and in communities. This article presents findings from an assessment of community-level and health facility service data collected during the first 13 months of DMPA-SC introduction in Benin. Because of this intervention, nearly 35,000 women received family planning counseling and 7,997 women chose DMPA-SC. At the community level, 3,111 DMPA-SC users were first-time users of modern contraception. The initial success of the DMPA-SC rollout in Benin shows promise for helping the country meet its reproductive health commitments.

Many stakeholders agree that integrating FP services and HIV prevention, care, and treatment services provides valuable opportunities to: increase access to contraception among clients of HIV services who do not wish to become pregnant; ensure a safe, healthy pregnancy and birth for clients who do wish to have a child; and provide valuable HIV prevention and support services to FP clients. Notably, the first of these opportunities contributes to preventing unintended pregnancy among women with HIV, which is one of the four cornerstones of a comprehensive approach to preventing vertical transmission of HIV. Depending on local needs and health facility capacity, the extent to which FP and HIV can be integrated differs, particularly when introducing FP in HIV services. All HIV services that integrate FP should offer: screening for unmet need for photo: Alden Nouga Pathfinder International Ethiopia has extensive experience implementing family planning (FP)/HIV integration through public health centers (HCs) and community networks. This brief describes our approach and its evolution and scale-up over time. It presents our experience in relation to the recommendations of World Health Organization (WHO) guidelines on FP/HIV integration and also outlines next steps and recommendations. Integrating Family Planning and HIV in Ethiopia: An Analysis of Pathfinder’s Approach and Scale-Up november 2011 2 Integrating Family Planning and HIV in Ethiopia: An Analysis of Pathfinder’s Approach and Scale-Up | Pathfinder International 3 contraception; promotion of dual method use; provision of condoms and other contraceptives according to training and availability; accurate information about all contraceptive methods; counseling for women or couples with HIV who desire a safer pregnancy; and referrals for contraceptive methods that the provider is not able to directly offer

The Integrated Family Health Program (IFHP) is a five-year USAID-funded program to promote an integrated model for strengthening maternal and child health, family planning (FP), and reproductive health services for rural and underserved populations in Ethiopia. Led by Pathfinder International and John Snow, Inc. in partnership with the Consortium of Reproductive Health Associations, IFHP has pursued scale-up of community-based provision of Implanon since 2009. Active in four regions of Ethiopia, IFHP’s Implanon scale up efforts support the government in enabling underserved rural communities to access this long-acting family planning (LAFP) method at the village level through task-shifting to Ethiopia’s health extension worker (HEW) cadre. In August 2011, the project completed the second year of its four-year timeline. This technical brief presents scale-up progress to date, and recommendations for future efforts

The International Centre for Diarrhoeal Disease Research, Bangladesh, has launched a field experiment in two rural thanas of Bangladesh to test the transferability of its successful health and family planning experiment in Matlab to the Ministry of Health and Population Control service system. This paper reviews the Matlab experiment with particular attention to its organization and identifies elements for transfer. The intervention strategy and operations research design of the new experiment are discussed. The proposed design follows an organization development strategy in which collaborative diagnostic research is used to foster institutional change. PIP: The International Center for Diarrheal Disease Research, Bangladesh has launched a field experiment in 2 rural thanas of Bangladesh to test the transferability of its successful health and family planning experiment in Matlab to the Ministry of Health and Population Control service system. The 1st family planning experiment began in 1975 and concentrated on the household distribution of contraceptives. It was further designed to provide a broad range of contraceptive and immunization services and oral rehydration therapy. Strong management control is vested in the non-medical, male supervisory staff. Maternal and child health services were later combined with the family planning project. This extension project has 2 components: an intervention strategy and a research strategy to assess the efficacy of the program. The analysis of the effects of this extension program is achieved through the longitudinal observation of households with a sample registration system. The proposed design follows an organization development strategy in which collaborative diagnostic research is used to foster institutional change. The original Matlab experiment posited that a significant proportion of clients desire to limit or space childbearing, but lack contraceptive services for doing so. The experiment demonstrated that there is a set of conditions under which a significant proportion of a rural Bangladeshi population will use contraception, and thereby reduce fertility. In transferring the programs to the supervision of the Ministry of Health, a number of modes were used: 1) use of a team appraoch, especially on household distribution; 2) train more community workers, especially females, and use teams of both males and females; 3) develop a Tertiary Health Center referral system, especially for sterilization; 4) enlarge training of present workers to include better preventive and MCH care; and 5) arrange monthly meetings of union-level workers at the field centers. No change in salary structure or administrative structure was planned.

Provision of injectable contraception by community health workers (CHWs) is a feasible, safe, and effective way to increase access to contraception for underserved populations. Efforts to expand community-based access to injectable contraception (CBA2I) are ongoing in more than a dozen countries in sub-Saharan Africa. At least half of these countries are taking measures to scale up CBA2I, which has prompted the global health community to address the growing need for systematic guidance on sustainable scale-up practices. Global guidance promotes the practice and encourages decision makers to think beyond pilot studies and demonstrations to the expansion of the practice. The following case studies review the different steps involved in the expansion of CBA2I in Uganda and Madagascar. The demand for injectable contraception is high in these two countries, but access to family planning (FP) services is limited in the rural areas. Before initiating pilot studies, both countries had existing community-based distribution (CBD) programs but did not permit CHWs to provide injectable contraception. Despite these similarities, the two countries pursued different approaches to the expansion of CBA2I—particularly with respect to the timing of policy change. In Madagascar, a policy change triggered the process. In Uganda, a pilot study led to the gradual expansion of services, which in turn led to a formal policy change. Both approaches can lead to success. The contrasting examples of Madagascar and Uganda can provide value lessons to implementers in other countries whose circumstances may mirror one or the other situation. The case studies are based on country reports, interviews with current and former in-country implementers, and the scale-up literature. Use of the term “Scale Up” The term “scale up” is used with various meanings in the reproductive health literature, and readers often bring their own assumptions to its interpretation. For this document, “scale up” refers to the geographical expansion or replication of a service into new areas of a country, which is sometimes referred to as “horizontal” scale up. Some people use the term scale up in a broader way, to include both geographical expansion as well as changes in national policies, guidelines and other health systems issues. Some refer to these systemic changes as “vertical” scale up. This document treats “policy change” separately from scale up, to identify the key steps involved in these two case studies.

International initiatives, including the Millennium Development Goals and the U.S. Government’s Global Health Initiative, are increasingly recognizing that gender strongly influences the health outcomes of women, men, and children. Evidence shows that gender inequality is a significant barrier to achieving improved family planning and reproductive health. Multiple studies have shown that gender factors, such as women’s status and empowerment (i.e., in education, employment, intimate partner relationships, and reproductive health), are linked with women’s capacity t access and use maternal health services, a critical component of maternal health (Gill et al., 2011). Still, family planning is typically viewed as the responsibility of women, with programs targeting women and overlooking the role of men—even though men’s dominance in decision making, including contraceptiv use, has significant implications for family planning (Schuler et al., 2011) and access to reproductive health services (Hou and Ma, 2011). Relevant literature indicates that the incorporation of strategies to address gender inequality can lead to improved health and program outcomes (Barker et al., 2007; Rottach et al., 2009). Many donors and program implementers have begun to incorporate strategies and approaches that address gender barriers and constraints. However, it is not clear that regular attention is being paid to gender factors during program scale-up. Gender factors influence a range of scale-up processes, including the choice of which practices to bring to scale, methods of scale-up, and strategies for reaching target populations. Throughout the scale-up process greater awareness of underlying gender norms and factors could strengthen scale-up efforts through improved understanding of the family planning and maternal, neonatal, and child health (FP/MNCH) issues at hand. A more in-depth understanding of the situation informs development of strategies for how to increase reach and access to and use of the intervention. We conducted a literature review to identify and analyze whether systematic attention to gender factors during the planning and process of scaling up FP/MNCH programs improves the effectiveness of that process. Our hypothesis is that incorporating gender strategies during program scale-up would in fact achieve better programmatic outcomes (e.g., wider availability of health services, health interventions institutionalized and sustained) and health outcomes (e.g., increased contraceptive prevalence rate, decreased maternal mortality rate) among their clients.

In the field of reproductive health, investigation of the transfer of knowledge gained from demonstration and pilot projects to large public-sector programs typically has not been considered a relevant domain for research or other investigation. This article draws on a range of research in the social sciences and presents two frameworks for understanding the critical attributes of successful expansion of small-scale innovations. Seven key lessons are developed using examples from family planning where scaling up was an explicit objective, including the early Taichung Study of Taiwan, the Chinese Experiment in Quality of Care, the Bangladesh MCH–FP Extension Project, the Navrongo Project in Ghana, and the Reprolatina Project in Brazil. Unless small, innovative projects concern themselves from the outset with determining how their innovations can be put to use on a larger scale, they risk remaining irrelevant for policy and program development.

Background
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

The introduction of new contraceptive technologies has great potential for expanding contraceptive choice, but in practice, benefits have not always materialized as new methods have been added to public-sector programs. In response to lessons from the past, the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP) has taken major steps to develop a new approach and to support governments interested in its implementation. After reviewing previous experience with contraceptive introduction, the article outlines the strategic approach and discusses lessons from eight countries. This new approach shifts attention from promotion of a particular technology to an emphasis on the method mix, the capacity to provide services with quality of care, reproductive choice, and users\' perspectives and needs. It also suggests that technology choice should be undertaken through a participatory process that begins with an assessment of the need for contraceptive introduction and is followed by research and policy and program development. Initial results from Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Vietnam, and Zambia confirm the value of the new approach. PIP: In response to difficulties associated with the introduction of new contraceptive technologies to public sector service systems, the UNDP/UNFPA/WHO/World Bank Special Program of Research, Development, and Research Training in Human Reproduction has formulated a new model. The strategic approach to contraceptive introduction shifts the emphasis from the promotion of a particular technology to quality of care issues, a reproductive health focus, and users\' perspectives and needs. It further entails a participatory approach with collaboration among governments, women\'s health groups, community groups, nongovernmental providers, researchers, international donors, and technical assistance agencies. The underlying philosophy is that method introduction should proceed only when a system\'s ability to provide high-quality services exists or can be generated. Since 1993, WHO has provided support for the implementation of this perspective in public sector programs in Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Viet Nam, and Zambia. Preliminary assessments in these countries revealed major structural, managerial, and philosophical barriers to high-quality family planning services. In cases where assessments have indicated the feasibility of new method introduction, this has been implemented through a carefully phased, research-based process intended to encourage the development of appropriate managerial capacity and to promote a humanistic philosophy of care.

Senegal has recently emerged as a leader in West Africa in the extension of postabortion care (PAC). This paper describes the extension of PAC to the district level in Senegal, where complications of abortion continue to claim too many women’s lives. Between November 2003 and June 2005, Management Sciences for Health introduced PAC services in 23 districts covering more than half the population of Senegal. The availability of PAC rapidly increased in both health centers and health posts. The proportion of health centers with a provider trained in PAC and that offered PAC services increased from 39% in 2003 to 100% in 2005. In 300 health posts, the proportion increased from 0% in 2003 to 72% in 2006. The number of women who sought treatment for an incomplete abortion at a health center more than doubled between 2003 and 2005. The availability of PAC services in the 23 health centers probably contributed to this increase, as did community education efforts. The proportion of women with incomplete abortions who received counseling before leaving a facility increased from 36% in 2003–04 to 82% in 2005. Of those who received counseling, the proportion leaving a facility with a family planning method rose almost fourfold in two years, from 15% in 2003 to 56% in 2005.

Successfully implementing and scaling up improvements to reproductive health services requires a strategic approach. The process must be participatory, listening to and learning from a wide range of stakeholders, especially the health services organization adopting the innovation and their clients, the consumers of health services. This goal can be achieved by following a concerted and deliberate process. There to commitment the makes Initiative FP2020 the, planning family of field the In. world the around modern using women million 120 another of goal the sets and planning family for need unmet reduce to access universal for call Goals Development Sustainable The. 2020 by methods contraceptive and) 7.3 Goal (2030 by, planning family for including, services care-health reproductive and sexual .(6.5 Goal (rights reproductive and rights health reproductive and sexual to access universal service proven and promising introduce to effort concerted a through only achieved be can goals These .programmes broader into projects scale-small existing expand to and widely more improvements Development Millennium the of many of achievement the and pandemic HIV the to response The in efforts their align programmes many when met be can goals ambitious that demonstrate Goals .goal common a of pursuit and planning family in practices best of up-scale and adoption the inhibit can barriers many, However information sharing of culture limited the often is obstacles major the Among. fields development other about uncertainty is obstacle Another. impact little has shared not is that knowledge: knowledge and improve to experience local and research through gained knowledge the applying about go to how guide concise This. crucial is process step-by-step, systematic A. scale large the on programmes and implement, choose to how for process proven a sharing by obstacles these address to seeks .services in improvements up scale

Broadening contraceptive choice, improving quality of care, and ensuring reproductive rights are central and related concerns in the delivery of family planning services. They are also fundamental elements of the vision of reproductive health outlined at the International Conference on Population and Development (ICPD) in Cairo in 1994. This guidebook describes how to conduct a strategic assessment that identifies actions to address these concerns. Because the assessment uses a reproductive health framework, it can also lead to decisions about a broad range of reproductive health care issues. Although the assessment described herein can stand alone, it was developed by the World Health Organization (WHO) as the first stage in a larger three-stage methodology for policy and programme development at the national level. This guide is primarily designed for use by the programme managers, policy-makers and national leaders who make decisions about introducing contraceptives and other fertility regulation technologies into health service delivery systems. This guide provides detailed information on how to plan and implement a strategic assessment to assist in making these decisions. Donor and international agency representatives, women’s health advocates, community leaders and others with an interest in improving reproductive health care may also find the guide of interest.

Integrated service delivery approaches have shown promise to increase use of services including postpartum family planning (PPFP) by young, first-time mothers (FTMs) but have proven challenging to scale and institutionalize. Integration adds complexity, requiring careful assessment of effects on a range of key system functions from demand creation and service delivery to oversight and governance. Through an innovative design process, we selected approaches to increase FTMs’ PPFP use through existing health systems. We generated programmatic options and then sought to select approaches based on (1) potential impact on FTMs’ PPFP uptake and (2) potential to institutionalize in the health system. The latter represented an innovation in addressing management systems’ drivers of scalability and sustainability; to accomplish it, we developed a participatory design process to assess the potential of an approach to be institutionalized in a specific context.

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.

The slide doc, “Learning from Five Norms Shifting Interventions Going to Scale,” highlights top Passages lessons on scaling NSIs. It represents the essential findings of a comparative analysis of five interventions: Girls Holistic Development (Grandmother Project in Senegal), Growing Up GREAT! (Save the Children in DRC), Husbands’ Schools (UNFPA and SonGES in Niger), Masculinité, Famille, et Foi (Tearfund in DRC), and Terikunda Jékulu or TJ (IRH in Mali). As Passages began, there was (and still is) relatively little documented evidence on NGO experiences of scaling interventions that aim to shift community norms. There were questions about how norms-shifting interventions could be scaled while maintaining core NSI norms-change mechanisms. Passages comparative analysis of implementation and research findings contributes to growing evidence that it is possible to scale NSIs and achieve similar normative and behavioral shifts in new communities with new implementers. Over six years, Passages partners, grounded in scale-up concepts and frameworks, documented and supported scale-up technically and evaluatively. Intervention and IRH staff developed learning questions that guided small and large studies to answer a range of scale-up implementation questions and norms-shifting effects. They explored expansion, institutionalization, adaptation aims and achievements, and partnering strategies with Ministries, a Congregational network, and local services. This slide doc showcase their work analyzing key wins, challenges, and lessons in planning and partnering for scale-up, supporting implementation by new scale-up partners, and the utility of using monitoring-evaluation-learning approaches and program theories of change to ensure common focus on normative and behavioral outcomes of scaling NSIs.

Post-abortion care (PAC), an innovation for treating women with complications of unsafe abortion, has been introduced in public health systems around the world since the 1994 International Conference on Population and Development (ICPD). This article analyzes the process of scaling-up two of the three key elements of the original PAC model: providing prompt clinical treatment to women with abortion complications and offering post-abortion contraceptive counseling and methods in Bolivia and Mexico. The conceptual framework developed from this comparative analysis includes the environmental context for PAC scale-up; the major influences on start-up, expansion, and institutionalization of PAC; and the health, financial, and social impacts of institutionalization. Start-up in both Bolivia and Mexico was facilitated by innovative leaders or catalyzers who were committed to introducing PAC services into public health care settings, collaboration between international organizations and public health institutions, and financial resources. Important processes for successful PAC expansion included strengthening political commitment to PAC services through research, advocacy, and partnerships; improving health system capacity through training, supervision, and development of service guidelines; and facilitating health system access to essential technologies. Institutionalization of PAC has been more successful in Bolivia than Mexico, as measured by a series of proposed indicators. The positive health and financial impacts of PAC institutionalization have been partially measured in Bolivia and Mexico. Other hypotheses—that scaling-up PAC will significantly reduce maternal mortality and morbidity, decrease abortion-related stigma, and prepare the way for efforts to reform restrictive abortion laws and policies—have yet to be tested. Bolivia Mexico Scale-up Unsafe abortion Post-abortion care Abortion

Problem
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.

Background
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.

This article addresses women\'s participation in an organization development project designed to improve public sector family planning and reproductive health services in Brazil. Although community women collaborated in aspects of the intervention and research, the project nonetheless raises the basic question whether such involvement of community women does or does not correspond to what scientific writers consider to be the essence of participatory research. We review key project features in the context of recent literature and conclude that although the project is committed to the sharing of power and control, it does not fully correspond to the characteristics of participatory research. Moreover, we argue that given the project\'s central focus on reproductive health outcomes, complete adherence to the process-oriented, pure version of participatory research would have been inappropriate.

As it moved from inception to a national program, the Egyptian postabortion care initiative used a highly flexible, innovative management style that was consistent with contemporary theories of how to diffuse innovation and scale up pilot activities. During the pilot study and initial expansion, the program maintained a strictly defined sense of identity as a postabortion research activity, achieving rapid success and demonstrating promise that drew the attention of innovative managers and policymakers. However, in this phase, the program’s replication was limited to carefully controlled circumstances, and the program failed to create circumstances for its scaling-up: It did not create broad enough partnerships or integrate the new services into an existing program. Furthermore, the strategy modeled on family planning programs’ strategy for introducing new contraceptives was not functional for postabortion care, because of sensitivities regarding abortion. As an active communication program brought together larger and larger groups of clinicians, and Ministry of Health and Population managers spurred dialogue about the clinical experience and knowledge gained, strategies for how to proceed were identified. Ownership of the postabortion program passed to the national Safe Motherhood Program, which incorporated most elements of the service delivery package and did away with the term “postabortion care.” This process of unbundling and relearning was essential to the integration of the postabortion care model into a larger program. Postabortion programs in other settings can learn from this experience and seek out partnerships with national programs that are working to improve maternal health services. The experience with the Egyptian postabortion care program also provides insights into policy-making associated with highly sensitive services. Postabortion initiatives will never be able to entirely avoid the politically charged atmosphere unique to abortion, particularly in settings where access to induced abortion services is legally restricted. Further, it is unlikely that a single policy advocate (or a committed few) will take a public stance and push for postabortion care–related reforms. Although the research program benefited from the support of farsighted decision-makers within the government and the donor community, expansion into a national program occurred only in the context of a larger effort to improve all types of obstetric services, and was not the result of a policy change specific to postabortion care. In such contexts, decisions related to abortion are made very slowly, and service delivery innovations must become usual and customary practices before a policy will change. The lag in critically important operational policy decisions (e.g., approval of the commercial importation of manual vacuum aspiration instruments) requires the long-term commitment of the program’s international supporters.

As a partner on the Frontiers in Reproductive Health Program from 1998 to 2004, Tulane furthered progress toward all three of the program’s intermediate results. Tulane contributed to IR1, innovative interventions tested to improve reproductive health through the Small Grants program, which generated research, and through the evaluation component. In assessing utilization, Tulane helped research staff understand the impact of their studies on reproductive health policies and programs as well as factors that affect this impact. In identifying these factors, researchers are able to take a more proactive approach to promoting utilization, which is the focus of IR2, research results disseminated and utilized. In IR3, Tulane was involved in more discrete capacity building activities. These included working with FRONTIERS/Washington 54 DC staff to modify the IR3 results framework according to new directions in capacity building after the first four years, developing a standard research protocol for systematic screening of services, and developing and facilitating a workshop on operations research for program managers. Through the internship program, selected Tulane students were provided opportunities to work on the design, implementation and management of operations research reproductive health projects. Currently, Tulane University is considering adding a course on Introduction to Operations Research to its academic program in International Health and Development.

The Nigerian Urban Reproductive Health Initiative (NURHI) aims to eliminate supply and demand barriers to contraceptive use and make family planning a social norm in Nigeria. The initiative, which is funded by the Bill & Melinda Gates Foundation, consisted of two 5-year phases. The first phase concluded in 2015, and the second phase ran from 2015 – 2020.

Research projects demonstrating ways to improve health services often fail to have an impact on what national health programmes actually do. An approach to evidence-based policy development has been launched in Ghana which bridges the gap between research and programme implementation. After nearly two decades of national debate and investigation into appropriate strategies for service delivery at the periphery, the Community-based Health Planning and Services (CHPS) Initiative has employed strategies tested in the successful Navrongo experiment to guide national health reforms that mobilize volunteerism, resources and cultural institutions for supporting community-based primary health care. Over a 2-year period, 104 out of the 110 districts in Ghana started CHPS. This paper reviews the development of the CHPS initiative, describes the processes of implementation and relates the initiative to the principles of scaling up organizational change which it embraces. Evidence from the national monitoring and evaluation programme provides insights into CHPS\' success and identifies constraints on future progress. community-based, health service, health officer, innovation, scaling up

Despite the advances made in the medical management of postabortion complications and the accumulation of evidence on feasibility and sustainability of program responses, much remains to be done to ensure that the momentum generated does not flag. Needs have been identified, interventions are well-known and know-how is available for program design and implementation. Joint statements from international organizations and leaders, such as the one on the importance of strengthening the family planning component of postabortion care issued in September 2009 by the International Federation of Gynecology and Obstetrics, International Confederation of Midwives, International Council of Nurses and USAID

Unsafe abortion's significant contribution to maternal mortality and morbidity was a critical factor leading to liberalization of Nepal's restrictive abortion law in 2002. Careful, comprehensive planning among a range of multisectoral stakeholders, led by Nepal's Ministry of Health and Population, enabled the country subsequently to introduce and scale up safe abortion services in a remarkably short timeframe. This paper examines factors that contributed to rapid, successful implementation of legal abortion in this mountainous republic, including deliberate attention to the key areas of policy, health system capacity, equipment and supplies, and information dissemination. Important elements of this successful model of scaling up safe legal abortion include: the pre-existence of postabortion care services, through which health-care providers were already familiar with the main clinical technique for safe abortion; government leadership in coordinating complementary contributions from a wide range of public- and private-sector actors; reliance on public-health evidence in formulating policies governing abortion provision, which led to the embrace of medical abortion and authorization of midlevel providers as key strategies for decentralizing care; and integration of abortion care into existing Safe Motherhood and the broader health system. While challenges remain in ensuring that all Nepali women can readily exercise their legal right to early pregnancy termination, the national safe abortion program has already yielded strong positive results. Nepal's experience making high-quality abortion care widely accessible in a short period of time offers important lessons for other countries seeking to reduce maternal mortality and morbidity from unsafe abortion and to achieve Millennium Development Goals.

On the occasion of the tenth anniversary of the International Conference on Population and Development, UNFPA, the United Nations Population Fund, is pleased to issue this pocket edition of the ICPD Programme of Action, which was adopted by 179 governments in 1994, and the Key Actions for its further implementation, which were adopted by the United Nations General Assembly in July 1999. The Cairo Conference, held from 5 to 13 September 1994, was the largest intergovernmental conference on population and development ever held. A total of 11,000 participants—from governments, the United Nations, intergovernmental organizations, non-governmental organizations and the media—contributed their expertise to make the Conference a critical success. The Cairo Conference moved population policy and programmes away from a focus on human numbers to a focus on human lives. It put the emphasis where it should be: on improving the lives of individuals, and increasing respect for their human rights. Delegates from all regions and cultures agreed that reproductive health is a basic human right. The Programme of Action underscores the integral and mutually reinforcing linkages between population and development. It urges the empowerment of women both as a highly important end in itself and as a key to improving the quality of life for everyone. At Cairo, the international community reached consensus on three quantitative goals to be achieved by 2015: the reduction of infant, child and maternal mortality; the provision of universal access to education, particularly for girls; and the provision of universal access to a full range of reproductive health services, including family planning. These ICPD goals are reinforced by the agreements of other global United Nations conferences of the 1990s and, most recently, by the Millennium Summit in September 2000. Indeed, the ICPD goals are essential for meeting the Millennium Development Goals to reduce widespread poverty, hunger, disease and gender inequality by 2015. The Programme of Action estimated that $18.5 billion annually, in national resources and international assistance, would be required by the year 2005 to implement its recommendations, and called on governments to make those resources available. At the midway point, funding iii remains a critical concern, with international donors falling far short of providing their agreed one third share of the required funds. The adoption of the Programme of Action marked the beginning of a new era of commitment and willingness on the part of governments, the international community and civil society to integrate population concerns into all economic and social planning and policy-making. The five-year review showed that the ICPD goals are still valid and that much progress had been made in advancing them. At the same time, it revealed that much greater and urgent action was needed to reduce maternal morbidity and mortality, address the sexual and reproductive health needs of adolescents and young people, prevent the spread of HIV/AIDS, and provide reproductive health care to women and youth in emergency situations. The Key Actions adopted at the special session of the General Assembly affirm the ICPD goals and provide a set of benchmarks for achieving them. It remains our collective task to strengthen and expand initiatives to meet the goals of the Programme of Action so that present and future generations will enjoy a better quality of life.

Background:
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.

Over the last four years CUSP has reflected critically on what it takes to adapt and scale our approaches effectively and ethically. During 2020 and 2021 we focused on what we would recommend to achieve effective, ethical and sustainable adaptation and expansion of our approaches. We explored what ‘feminist scale’ might look like and mean. While previously, as a group we focused on the challenges we encountered with adaptations and expansions of our program, this time we considered what kind of adaptation and expansion we would like to see. Our methodologies were based on feminist principles, but we found that these principles were frequently lost when others took them to scale: namely, the focus shifted to numbers, geographic coverage, efficiencies, rather than on the process of scale. We have many stories of how organizations have used our programs without providing follow-up support to enable them to grow their newly germinated ideas into action. Most of us had not heard the term ‘feminist scale’ but rather noted that the term ‘feminist movement(s)’ was common. Would using new terminology broaden our vision of scale and better communicate the values behind our work?

In summary, CUSP’s collective practice-based experiences and insights for scaling social norms change are: 1. Prioritize accountability to communities 2. Fully understand the principles of, and align with, the values of the methodology 3. Ensure adequate time and funding for programming 4. Maintain fidelity to the elements of the original methodology 5. Involve originators 6. Re-examine the role of government and international organizations in effective and ethical scaling

In the past decades, donors and development actors have been increasingly mindful of the evidence to support long-term, dynamic social norms change. This paper draws lessons and implications on scaling social norms change initiatives for gender equality to prevent violence against women and girls (VAWG) and improve sexual and reproductive health and rights (SRHR), from the Community for Understanding Scale Up (CUSP). CUSP is a group of nine organisations working across four regions with robust experience in developing evidence-based social norms change methodologies and supporting their scale-up across various regions and contexts. More specifically, the paper elicits learning from methodologies and experiences from five CUSP members - GREAT, IMAGE, SASA!, Stepping Stones, and Tostan. The discussion raises political questions around the current donor landscape including those positioned to assume leadership to take such methodologies to scale, and the current evaluation paradigm to measure social norms change at scale. CUSP makes the following recommendations for donors and implementers to scale social norms initiatives effectively and ethically: invest in longer-term programming, ensure fidelity to values of the original programmes, fund women\'s rights organisations, prioritise accountability to their communities and demands, critically examine the government and marketplace\'s role in scale, and rethink evaluation approaches to produce evidence that guides scale-up processes and fully represents the voices of activists and communities from the Global South. Keywords: gender equality; scale-up; sexual and reproductive health and rights; social change; social norms; violence against women.

Social norms are the shared but unwritten rules that govern behavior, and beliefs about which behaviors are appropriate, within a given social group. Social expectations related to young people’s sexuality and reproductive health may support healthy behaviors, or they may have a harmful impact. Strategic interventions can influence the norms that surround adolescent and youth sexual and reproductive health (AYSRH). Norms-shifting interventions (NSI), often implemented at the community level, address actual norms (versus norms perceived by outsiders), create positive new norms, and engage a wide range of people at multiple levels. Done successfully, NSI can modify social norms to support healthy behaviors. While good practice is to design your pilot NSI to be scalable from the start - easy to implement, effective, and acceptable to communities and other stakeholders - the questions will be asked, not only after a pilot deems the effort scale-worthy but throughout a scale-up process: Should your organization take the plunge to expand the NSI into new areas, often with new counterpart organizations? Should your organization attempt to institutionalize the NSI with an eye to sustainability, sometimes in a changed policy or program environment? If the answers are yes, how can your organization do scale-up in a way that maintains the NSI’s effective elements? What resources do you need, and how should your and other organizations prepare for the scale-up process? How might the external environment be leveraged to support scale-up in new areas with new populations?

Of the world’s 570 million farmers, 72% work on two hectares or less, and women’s labor comprises at least 50% (FAO, 2014). Small farms are responsible for 80% of world food production, making them key to addressing looming global food shortages (Lowder et al., 2016). Small farms in developing countries navigate a myriad of challenges, including access to information, quality inputs, capital, markets, and among others, land (FAO, 2014). These challenges can be exacerbated for women and other marginalized groups of people due to social normatives within their communities (Petesch, Badstue, & Prain, 2018; Polar et al., 2017; Rola‐Rubzen et al., 2020). Inclusive innovation to address agriculture productivity and loss gaps is tantamount to equitable global food security (FAO, 2014; FAO, 2011). However, many innovations still fail to help stimulate disruption in gender or social inequities, and some even do additional harm. Increasing use of an innovation, referred to as ‘scaling,' is critical to impact at a community or regional level, and is often seen as necessary to support Agriculture Research for Development (AR4D) outcomes (Sartas et al., 2020). Several scaling support tools and methodologies have been developed to assist researchers and practitioners in scaling processes. However, little practical attention has been given to the specific cross-section of gender and relevant diversity within scaling tools and methodologies. This narrative literature review begins to address this by answering: 1) What are unique gender considerations when scaling agricultural innovations?; and 2) What are appropriate methods and approaches for collecting data on these unique gender considerations? Our review finds six points of attention to reflect upon unique gender considerations when innovating and scaling innovation: i) Comprising research and project teams, ii) Designing agricultural innovations, iii) Communicating and extension of innovation, iv) Choosing scale models: entrepreneurship and business development, v) Reinventing and changing technology, and vi) Engaging with the political economy of innovation. Methods to collect necessary data to accurately reflect on these considerations and avoid unintended negative consequences for more gender responsible scaling are also presented. Finally, the literature review is situated in a perspective that more attention should be given to agricultural innovation and scaling support tools and methodologies to address gender or socially marginalized groups.

Introduction
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.

As part of a multifaceted effort to respond to the needs of young people more effectively, the Ministry of Health of the Republic of Moldova established pilot Youth Friendly Health Centres (YFHC) in 2001. In 2005, after 12 YFHC were set up and implemented, the MOH identified that while they were serving a useful function, four problems remained needed to be addressed – the lack of an operational definition of the term youth friendly health services, the lack of objective data on the added value of the existing YFHC, the low coverage of the existing YFHC and the almost complete reliance on donor agencies for funding the effort. The MOH addressed each of these problems systematically. While challenges still exist, the MOH has taken important steps to ensure that all young people in the country can obtain the health services they need.

- Adolescent pregnancy and childbearing can have negative health, social and economic consequences.
- 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

Some harmful practices are sustained by social norms—collective beliefs about what people expect from each other. Practitioners and researchers alike have been investigating the potential of social norms theory to inform the design of effective interventions addressing these practices in low- and middle-income countries. One approach commonly used to facilitate social norms change is community-based dialogs and trainings. This approach has often been criticized for not being cost-effective, as it usually includes a relatively small number of direct participants and does not allow for scaling-up strategies. In spite of some evidence (as for instance, the SASA! Program) that community dialogs can achieve social norms change, little exists in the literature about how exactly participants in community dialogs engage others in their networks to achieve change. In this paper, we look at the potential of “organized diffusion” as a cost-effective strategy to expand the positive effects of community-based interventions to participants’ networks, achieving sustainable normative shifts. We provide quantitative evidence from three case studies—Community Empowerment Program in Mali, Change Starts at Home in Nepal, and Voices for Change in Nigeria—showing that participants in community-based interventions can be effectively empowered to share their new knowledge and understandings systematically with others in their networks, eventually facilitating social norms change. Future community-based interventions intending to achieve social norms change would benefit from integrating ways to help participants engage others in their network in transformative conversations. Doing so has the potential to generate additional impact with little additional investment.

Introduction: From 2018 to 2020, Adolescents 360 (A360), aiming to increase demand for and voluntary uptake of modern contraception among adolescent girls 15–19 years, designed and scaled an intervention in Tanzania (Kuwa Mjanja) to 13 regions through project-funded expansion. In 2020, the project began to develop a strategy for its follow-on phase, focusing on program sustainability. In this process, funder priorities led to a decision to exit A360's programming in Tanzania over a 15-month exit period. A360 elected to pursue a process of expedited institutionalization of Kuwa Mjanja into government systems during this period.

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.

In 1999, the Population Council‟s Frontiers in Reproductive Health Program (FRONTIERS) and the Program for Appropriate Technology in Heath (PATH) collaborated with three Government of Kenya ministries – the Ministry of Education (MOE), the Ministry of Health (MOH), and the Ministry of Gender, Sports, Culture and Social Services (MGSCSS) to design and implement a multisectoral project with the following goals: To improve knowledge about reproductive health and encourage a responsible and healthy attitude towards sexuality among adolescents; To delay the onset of sexual activity among younger adolescents; To decrease risky behaviors among sexually active adolescents. Three interventions were piloted in Vihiga and Busia districts in the Western Province over a period of 30 months. The intervention implemented by MGSCSS addressed the sensitivity of adolescent sexual and reproductive health (ASRH) within the community, by improving support and promoting dialogue around this topic among parents and adolescents. The MOE educated inschool adolescents about ASRH issues through a life-skills curriculum presented through extracurricular sessions and peer educators. The MOH addressed the information and service needs, primarily of sexually active adolescents, by increasing access to adolescent friendly services and through peer educators. Key findings from the pilot project demonstrated that the three ministries could successfully implement the interventions with minimal support from FRONTIERS and PATH. Parent to child communication increased significantly and there was increased awareness about contraceptive methods, especially condoms, pills and injectables. Condom use for dual prevention of STIs and pregnancy became better known among adolescents. The level of awareness of specific STIs among all adolescents also increased significantly. The interventions reinforced disapproval of premarital sex and childbearing, and a particular disapproval for teen pregnancies. Some changes were also noted in behavioral indicators, including delayed onset of sexual activity, reduced number of sexual partners, reduced incidences of sexual violence, reduced levels of unplanned pregnancies as well as fewer school dropouts. The positive results of the pilot phase prompted a 20-month phase of adaptation and expansion of KARHP throughout the two pilot districts to enable the ministries to gain experience of implementing the services at the district level. Pilot materials and tools were revised and intersectoral committees set up at district and provincial level. The approach was then further scaled up throughout the remaining six districts of Western Province from June 2005 to May 2006. This province-wide scaling-up experience led to a further 13-month phase of replication, during which the model was introduced in two districts each of Eastern and Nyanza provinces in June 2006 to May 2007. This was followed by province-wide expansion by the USAID-funded APHIA partners. From June 2007 to May 2008, KARHP was introduced in Nairobi and Central Provinces. Despite the challenges of working with public sector, this program proved that multisectoral approaches that build the capacity of government ministries to mainstream ASRH services can lead to wide-scale expansion and sustainability of effective pilot models.

Between September 2018 and July 2019, Pathfinder International's Evidence to Action (E2A) Project, with support from USAID and in close collaboration with IntraHealth International's Neema Project, supported Senegal's Ministry of Health and Social Action (MSAS) to implement and plan for the scale-up of the “Postabortion Family Planning for Adolescents and Youth (PAFP-AY)” intervention. Utilizing the four steps of E2A’s project cycle depicted in figure 1 above, this technical brief describes the different stages in planning for scale-up as well as the key results we achieved.

In 1994, more than 10,000 participants, including representatives from 179 governments, United Nations agencies, as well as nongovernmental and civil society organizations convened in Cairo (Egypt) for the International Conference on Population and Development (ICPD). The conference adopted a forward-looking Programme of Action (PoA) that continues to serve as a comprehensive guide to development policies and programs that are centered around the improvement of people's health and well-being and the reduction of inequalities [[1]]. The PoA underscored the centrality of ensuring the sexual and reproductive health and rights (SRHR) of all people in the pathway to sustainable development [[1]]. The PoA also gave prominence to adolescents' SRHR and served as an impetus for increased investments and programs aimed at improving their health and well-being. In the 25 years following the ICPD, there has been increased international commitment to improving the health of adolescents (aged 10–19 years) and, in particular, their SRHR as evidenced by increased investments in adolescent SRHR programming. This supplement to the Journal of Adolescent Health brings together four papers that summarize the milestones that have been achieved in efforts to improve adolescent SRHR in the 25 years since the ICPD and the gaps that need to be addressed over the next 25 years. The first paper by Liang et al. [[2]] examines trends in key indicators of adolescents' SRHR and social and economic determinants of their SRHR during the 25 years since the ICPD. The second paper by Chandra-Mouli et al. [[3]] complements the first and provides an overview of policy and programmatic responses over the last 25 years by focusing on six aspects of adolescents' SRHR: pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstruation. Collectively, these two papers highlight the significant progress that has been made in enhancing adolescents' SRHR. For example, there is evidence of significant declines in adolescent pregnancy [[4]], child marriage [[5]], and female genital mutilation [[6]]; increased funding for programs and research targeting adolescents; and a significant growth in the number of evidence-informed policies, normative documents, and guidelines on adolescent-responsive SRHR programming. Despite the progress, several critical gaps remain. First, there remain substantial inequalities across and within countries in key indicators of adolescent health [[2]]. Second, some indicators such as intimate partner violence and reproductive cancers have worsened [[2]]. Third, efforts to implement adolescent SRHR policies and programs are impeded by extensive resistance to the provision of comprehensive SRHR information and services to adolescents because of social norms and taboos around adolescents' sexuality [[3]]. Fourth, the multiple factors that drive adolescents' SRHR demand complex programs that are often challenging to implement. Finally, an issue that remains largely silent in these papers is the limited focus on adolescent boys despite the PoA's emphasis that “Special efforts should be made to emphasize men's shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behavior, including family planning; prenatal, maternal and child health; prevention of sexually transmitted diseases, including HIV; prevention of unwanted and high-risk pregnancies” [[7]]. The third and fourth papers are forward looking and outline some of the actions that need to be taken to address existing gaps. Engel et al. [[8]] focus on shortcomings at service delivery level and note that adolescents “still risk falling into a policy and service-delivery gap where their specific SRHR health needs are overlooked.” To overcome the obstacles to efforts to enhance ASRHR, Engel et al. [[8]] emphasize the need for a comprehensive approach that addresses the broader social and economic determinants of SRHR to achieve sustainable impact. In their paper, they build on the Guttmacher-Lancet Commission for SRHR report [[9]] to outline specific recommendations to mainstream adolescent-responsive interventions at the legal, policy, systems, and community levels. In the fourth paper, Plesons et al. [[10]] highlight key challenges that impede adolescent-responsive actions at country level and some of the emerging opportunities that countries can leverage to overcome these challenges. They then outline five strategic actions that need to be taken to achieve progress: use political, governmental, and social support to strengthen adolescent SRHR programs; use available resources effectively and demonstrate impact; ensure that enabling laws and policies are widely communicated and applied; use available data and evidence to inform policies and programs; and manage implementation at scale with quality and equity. All four papers in this supplement reinforce the need for multisectoral interventions to address the wider social and economic determinants of adolescents' SRHR. Although the importance of multisectoral action is not in question, collaboration across multiple sectors is a complicated undertaking, and countries need practical guidance and support to create, implement, and assess multisectoral programs. The Global Accelerated Action for the Health of Adolescents (AA-HA!): Guidance to Support Country Implementation [[11]] provides guidance for multisectoral programming at country level. However, most countries, particularly those in low- and middle-income settings, are likely to require both technical and financial support to implement this guidance particularly for programming on a sensitive topic such as adolescent SRHR. Furthermore, countries must be supported to generate rigorous data and evidence to inform these programs. It is the editor's hope that as countries and key stakeholders reflect on the progress in the 25 years since the ICPD and chart the way forward, this supplement stimulates further investments to enable countries to implement evidence-based comprehensive SRHR programs and policies that will enhance the health and well-being of adolescent boys and girls.

Adolescent and youth reproductive health (AYRH) outcomes are influenced by factors beyond individual control. Increasingly, interventions are seeking to influence community-level normative change to support healthy AYRH behaviors. While evidence is growing of the effectiveness of AYRH interventions that include normative change components, understanding on how to achieve scale-up and wider impact of these programs remains limited. We analyzed peer-reviewed and gray literature from 2000 to 2017 describing 42 AYRH interventions with community-based normative change components that have scaled-up in low/middle-income countries. Only 13 of 42 interventions had significant scale-up documentation. We compared scale-up strategies, scale-up facilitators and barriers, and identified recommendations for future programs. All 13 interventions addressed individual, interpersonal, and community-level outcomes, such as community attitudes and behaviors related to AYRH. Scale-up strategies included expansion via new organizations, adapting original intervention designs, and institutionalization of activities into public-sector and/or nongovernmental organization structures. Four overarching factors facilitated or inhibited scale-up processes: availability of financial and human resources, transferability of intervention designs and materials, substantive community and government-sector partnerships, and monitoring capacity. Scaling-up multifaceted normative change interventions is possible but not well documented. The global AYRH community should prioritize documentation of scale-up processes and measurement to build evidence and inform future programming.

Introduction: Despite the existence of a legal policy framework, financing of adolescent and youth sexual and reproductive health (AYSRH) services has remained weak. External donors are the main financing agents, which has implications for the sustainability of service provision. International development partners have reduced funding for health programs from historically high levels. In Kenya, the health sector's budget allocation has remained below the 15% committed to under the Abuja declaration. With Kenya's devolved government structure, a greater proportion of financial resources are dedicated towards recurrent and structural expenses as opposed to addressing health systems gaps.

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.

Little is known about the nature and mechanisms of factors that facilitate or inhibit the scale-up and subsequent implementation of school-based adolescent sexual and reproductive health (ASRH) interventions. We present process evaluation findings examining the factors that affected the 10-fold scale-up of such an intervention, focussing on teachers\' attitudes and experiences. Qualitative interviews and focus group discussions with teachers, head teachers, ward education coordinators and school committees from eight schools took place before, during and after intervention implementation. The results were triangulated with observations of training sessions and training questionnaires. The training was well implemented and led to some key improvements in teachers\' ASRH knowledge, attitudes and perceived self-efficacy, with substantial improvements in knowledge about reproductive biology and attitudes towards confidentiality. The trained teachers were more likely to consider ASRH a priority in schools and less likely to link teaching ASRH to the early initiation of sex than non-trained teachers. Facilitating factors included teacher enjoyment, their recognition of training benefits, the participatory teaching techniques, support from local government as well as the structured nature of the intervention. Challenges included differential participation by male and female teachers, limited availability of materials and high turnover of trained teachers.

Purpose
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.

The importance of scaling up young adult reproductive health (YARH) programs is an emerging concern given the growing and changing needs of youth, the lack of effective programs to reach young people in many countries, the need to build widespread public acceptance for YARH programs, and shrinking resources in many areas. Although the term “scaling up” has few precise definitions, most definitions imply that the program extends services to more people in more places. As used in this tool, the term refers to the process of institutionalizing effective programs to achieve greater impact in terms of increasing the numbers of young people served, broadening the geographic coverage, and, sometimes, expanding mandates. This tool aims to improve program leaders’ and policymakers’ understanding of scaling up and to help them plan for scaling up their own YARH programs. Scaling up youth programs may bring a number of important gains. First, economies of scale may be achieved by reaching more young people. Scaled-up programs can reach beyond urban areas to provide services for youth in rural areas. Documentation and evaluation of efforts to scale up can contribute to the field’s understanding of how to design and implement at-scale programs. In deciding whether or not to scale up, programs need to consider four important factors: whether the program has been effective, how scaling up will affect the program’s impact, whether the increased scale will be sustainable, and what their objective of scale is. Four major approaches to scaling up YARH programs are: Planned expansion refers to a steady process of expanding the number of sites and the number of people served by a particular program model once it has been pilot tested. Association involves expanding program size and coverage through common efforts and alliances across a network of organizations. Grafting means adding a new initiative to an existing program, such as adding a sex education program to academic school programs or making family planning programs directed at adults “youth friendly.” Explosion is sudden implementation at a large scale, usually with its roots in high-level politics. Most YARH programs achieve scale-up through a combination of these approaches. Many programs also start out as pilot projects—smaller, simpler interventions that have more defined time limits—before they are taken to scale. Executive Summary Seven key ideas about scaling up YARH programs have emerged from the literature: Programs should prepare for scaling up by focusing on program development and institutionalization. Policy shapes program development and may inhibit or encourage efforts to scale up. Activists and program planners should build on existing institutions and infrastructure when scaling up. Committed leaders are needed to support, guide and sponsor the scaling-up process. The process of scaling up should be participatory and allow for flexibility. Program developers and policy advocates should anticipate obstacles and challenges to scaling up. Data, research, and monitoring and evaluation systems are crucial to scaling up effective programs. In general, the better developed a program is—and the more it is supported by favorable policy—the greater the chance that the program will be able to function at scale. These strengths enable a program to withstand shocks in the policy environment or changes within the program. This does not mean that every policy factor must be favorable, or that every program implementation step has to be accomplished. But the more that these ideal conditions are met, the more likely it is that programs will be successful at scaling up. It is critical to plan early for subsequent scaling up; to use a participatory process to include youth, staff members, and stakeholders; and to infuse the process with dynamic leadership. By identifying specific requirements of program development and a range of favorable policy factors in the design phase, the large tasks of program and policy development can be subdivided into more manageable steps to which planners and activists can devote particular attention. Identifying policy hurdles and obstacles in program development provides early warning regarding circumstances or conditions that may pose problems to program expansion. With key ingredients like leadership, staff, funding sources and advocates, programs can move beyond local origins to operate at scale. Program managers interested in scaling up should plan the building of policy advocacy and networking support activities into new YARH designs. They can also plan for staggered phases of local adaptation, and can build the program supports (administrative systems, training courses and curricula) on which successful scaling up depends. The last section of this tool provides a number of worksheets that will help YARH program leaders and policymakers prepare for the task of scaling up.

Wasting is a critical issue for child survival and development, with therapeutic treatment of severe cases recognised as an essential intervention for achieving global wasting and mortality targets. There have been many efforts to scale up severe wasting treatment over the past 10 years with the ultimate aim of achieving national and international coverage of a sustainable, quality service provided as an integral part of the health system and supported by a strong community base. However, progress is slow and only up to 25% of children who need treatment are currently accessing it. After completing a comprehensive scoping study on readyto-use therapeutic food (RUTF) in 2020 and in preparation for the ‘CMAM 20 Years On’ conference, Emergency Nutrition Network (ENN) considered that the time was right to synthesise reflections on the past decade of experiences of scaling up severe wasting treatment into routine primary health services. This report summarises key informant perspectives, supported by a literature review, to highlight the current state of the scale-up of severe wasting services while drawing out some of the key barriers and enablers of this process. This report does not aim to describe ENN’s perspective, but rather it offers a qualitative synthesis of the perspectives of key informants to provide an up-to-date snapshot of how people are thinking and acting on the topic of severe wasting treatment scale-up.

Introduction
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.

Scale-up is a non-linear change process at different levels of the health system. For scale-up, multiple strategies requiring simultaneous attention must be deployed. Equity, quality and leadership cut across all programme components. A positive policy environment and system strengthening are essential for scale-up. Other important conditions relate to resources, training, supervision and monitoring. Scaling up an emergency obstetric and neonatal care (EmONC) programme entails reaching a larger number of people in a potentially broader geographical area. Multiple strategies requiring simultaneous attention should be deployed. This paper provides a framework for understanding the implementation, scale-up and sustainability of such programmes. We reviewed the existing literature and drew on our experience in scaling up the Essential Steps in the Management of Obstetric Emergencies (ESMOE) programme in South Africa. We explore the non-linear change process and conditions to be met for taking an existing EmONC programme to scale. Important concepts cutting across all components of a programme are equity, quality and leadership. Conditions to be met include appropriate awareness across the board and a policy environment that leads to the following: commitment, health systems-strengthening actions, allocation of resources (human, financial and capital/material), dissemination and training, supportive supervision and monitoring and evaluation. emergency obstetric and neonatal care scale-up implementation

Interventions to promote exclusive breastfeeding have been estimated to have the potential to prevent 13% of all under-5 deaths in developing countries and are the single most important preventive intervention against child mortality. According to World Health Organization and United Nations Children Funds (UNICEF), only 39% infants are exclusively breastfed for less than 4 months. This review examines programme efforts to scale up exclusive breastfeeding in different countries and draws lesson for successful scale-up. Opportunities and challenges in scaling up of exclusive breastfeeding into Maternal and Child Health programmes are identified. The key processes required for exclusive breastfeeding scale-up are: (1) an evidence-based policy and science-driven technical guidelines; and (2) an implementation strategy and plan for achieving high exclusive breastfeeding rates in all strata of society, on a sustainable basis. Factors related to success include political will, strong advocacy, enabling policies, well-defined short- and long-term programme strategy, sustained financial support, clear definition of roles of multiple stakeholders and emphasis on delivery at the community level. Effective use of antenatal, birth and post-natal contacts at homes and through community mobilization efforts is emphasized. Formative research to ensure appropriate intervention design and delivery is critical particularly in areas with high HIV prevalence. Strong communication strategy and support, quality trainers and training contributed significantly to programme success. Monitoring and evaluation with feedback systems that allow for periodic programme corrections and continued innovation are central to very high coverage. Legal framework must make it possible for mothers to exclusively breastfeed for at least 4 months. Sustained programme efforts are critical to achieve high coverage and this requires strong national- and state-level leadership.

Objective:
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

Programs to reduce mortality among women and children are the target of new resources and redoubled commitment as the 2015 date for achieving the Millennium Development Goals approaches. The need for a common evaluation framework to guide the collection, analysis and synthesis of evidence is increasingly evident. This paper presents such a framework in four parts: (1) a conceptual model for the scale-up to MDGs 4 and 5 for maternal and child survival; (2) recommended indicators for each part of the model that bring together the work of various existing technical groups and prioritize a limited number of indicators for standardization and common use; (3) guidelines for documenting program implementation and contextual factors that may affect program implementation and its effectiveness in reducing maternal and child mortality; and (4) design considerations in evaluating the scale-up. We first present an overview of what is known and/or agreed upon within each of these areas, and in the discussion highlight areas of uncertainty or where there are gaps to be addressed. Evaluation Studies, Health Services, Health Status Indicators, Child Health Services, Child Survival, Maternal Health

There is a well-recognized need for empirical study of processes and factors that influence scale up of evidence-based interventions in low-income countries to address the ‘know-do’ gap. We undertook a qualitative case study of the scale up of chlorhexidine cleansing of the umbilical cord (CHX) in Bangladesh to identify and compare facilitators and barriers for the institutionalization and expansion stages of scale up. Data collection and analysis for this case study were informed by the Consolidated Framework for Implementation Research (CFIR) and the WHO/ExpandNet model of scale up. At the national level, we interviewed 20 stakeholders involved in CHX policy or implementation. At the district level, we conducted interviews with 31 facility-based healthcare providers in five districts and focus group discussions (FGDs) with eight community-based providers and eight programme managers. At the community level, we conducted 7 FGDs with 53 mothers who had a baby within the past year. Expanded interview notes were thematically coded and analysed following an adapted Framework approach. National stakeholders identified external policy and incentives, and the engagement of stakeholders in policy development through the National Technical Working Committee for Newborn Health, as key facilitators for policy and health systems changes. Stakeholders, providers and families perceived the intervention to be simple, safe and effective, and more consistent with family preferences than the prior policy of dry cord care. The major barriers that delayed or decreased the public health impact of the scale up of CHX in Bangladesh’s public health system related to commodity production, procurement and distribution. Bangladesh’s experience scaling up CHX suggests that scale up should involve early needs assessments and planning for institutionalizing new drugs and commodities into the supply chain. While the five CFIR domains were useful for categorizing barriers and facilitators, additional constructs are needed for common health systems barriers in low-income settings. Scale up, implementation, newborn health, Bangladesh, Chlorhexidine

Background
Chlorhexidine (CHX) cleansing of the umbilical cord stump is an evidence-based intervention that reduces newborn infections and is recommended for high-mortality settings. Bangladesh is one of the first countries to adopt and scale up CHX nationally. This study evaluates the implementation outcomes for the CHX scale up in Bangladesh and identifies and describes key milestones and processes for the scale up.

Methods
We adapted the RE-AIM framework for this study, incorporating the WHO/ExpandNet model of Scale Up. Adoption and incorporation milestones were assessed through program documents and interviews with national stakeholders (n = 25). Provider training records served as a measure of reach. Implementation was assessed through a survey of readiness to provide CHX at public facilities (n = 4479) and routine data on the proportion of all live births at public facilities (n = 813 607) that received CHX from December 2016 to November 2017. Six rounds of a rolling household survey with recently-delivered women in four districts (n = 6000 to 8000 per round) measured the effectiveness and maintenance of the scale up in increasing population-level coverage of CHX in those districts.

Results
More than 80 000 providers, supervisors, and managers across all 64 districts received a half-day training on CHX and essential newborn care between July 2015 and September 2016. Seventy-four percent of facilities had at least 70% of maternal and newborn health providers with CHX training, while only 46% had CHX in stock on the day of the assessment. The provision of CHX to newborns delivered at facilities steadily increased from 15 059 newborns (24%) in December 2016 to 71 704 (72%) in November 2017. In the final household survey of four districts, 33% of newborns were reported to receive CHX, and babies delivered at public facilities had 5.04 times greater odds (95% CI = 4.45, 5.72) of receiving CHX than those delivered at home.

Conclusions
The scale up of CHX in Bangladesh achieved sustained national implementation in public health facilities. Institutionalization barriers, such as changes to supply logistics systems, had to be addressed before expansion was achieved. For greater public health impact, implementation must reach deliveries that take place at home and in the private sector.

The Sustainable Development Goals, Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) and Nurturing Care Framework all include targets to ensure children thrive. However, many projects to support early childhood development (ECD) do not ‘scale well’ and leave large numbers of children unreached. This paper is the fifth in a series examining effective scaling of ECD programmes. This qualitative study explored experiences of scaling-up among purposively recruited implementers of ECD projects in low- and middle-income countries. Participants were sampled, by means of snowball sampling, from existing networks notably through Saving Brains®, Grand Challenges Canada®. Findings of a recent literature review on scaling-up frameworks, by the WHO, informed the development of a semistructured interview schedule. All interviews were conducted in English, via Skype, audio recorded and transcribed verbatim. Interviews were analysed using framework analysis. Framework analysis identified six major themes based on a standard programme cycle: planning and strategic choices, project design, human resources, financing and resource mobilisation, monitoring and evaluation, and leadership and partnerships. Key informants also identified an overarching theme regarding what scaling-up means. Stakeholders have not found existing literature and available frameworks helpful in guiding them to successful scale-up. Our research suggests that rather than proposing yet more theoretical guidelines or frameworks, it would be better to support stakeholders in developing organisational leadership capacity and partnership strategies to enable them to effectively apply a practical programme cycle or systematic process in their own contexts.

Background
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.

Peripheral-level birthing centers may be appropriate and effective in some circumstances if crucial systems requirements can be met. But promising models don’t necessarily scale well, so policy makers and program managers need to consider what requirements can and cannot be met feasibly at scale. Apparently successful components of the birthing center model, such as engagement of traditional birth attendants and use of frontline staff who speak the local language, appear conducive to use in other similar settings. In this issue of Global Health: Science and Practice, Stollak et al.1 report a positive experience with maternal-newborn services for remote, primarily indigenous communities in Guatemala. The work was done by an NGO and included an important focus on community outreach and cultural sensitivity. Services were made more accessible by establishing birthing centers (Casas Maternas) in communities where such services hadn’t previously been available. They were staffed by skilled birth attendants (SBAs)—locally hired auxiliary nurses—who spoke the local language. The project also cultivated relationships with traditional birth attendants, who were made welcome to support women giving birth in the Casas Maternas. In addition, the project facilitated reliable transfer of complicated cases to higher-level care. This case raises 2 important issues, one specific to maternal-newborn care and the other more broadly relevant to generalizability or transferability from small scale to large.

This paper describes eight major steps in the process of scaling up from the experience of SFC/ Bolivia. From 1995 through 1997 SCF/Bolivia working with the Ministry of Health PROCOSI (a national PVO umbrella group) and other partners expanded the Warmi Project from a pilot in three rural communities in one province to a national program affecting 513 communities in Bolivia. Their experience demonstrates how participatory approaches specifically the community action cycle can be brought to national scale through flexibility inter-institutional coordination and establishment of common goals. As the Warmi model expands to other countries in Latin America and Africa health planners need to examine lessons learned from this seminal work in Bolivia.

The Law for the Provision of Free Maternity and Child Care (LFMC) was passed by the Ecuadorian Congress in 1994 but only began to be operationalized following amendments to the law in 1998. The LFMC seeks to reduce maternal and infant mortality and improve women and children’s health by guaranteeing access to free prenatal care, labor and delivery, and basic child health services. The Ministry of Public Health has applied the LFMC throughout its facilities since 1999. The number of individuals who received health services covered by the LFMC has also steadily increased: in 1999, the number of individuals covered was 1,600,000, while in 2002 it reached 2,248,000 women and children. Women are the main beneficiaries of the LFMC, accounting for 70% of the population served by the program. The mechanisms employed by the LFMC have become increasingly important tools for the improvement of healthcare coverage and quality in Ecuador. Among these mechanisms are the publication of clinical guidelines, calculation of costs for reimbursement of services, reimbursement to facilities based on service volume, implementation of a continuous quality improvement system with practical tools to measure and improve quality, management agreements with municipalities for co-management of healthcare services, and the organization of users’ committees to ensure the quality and responsiveness of services. The present document reports on an operations research study conducted by the Quality Assurance Project (QAP) to examine the process of institutionalizing a Continuous Quality Improvement (CQI) process within the context of the reforms introduced by the Law for the Provision of Free Maternity Services and Child Care. The objectives of the study were: a) Describe and document the process, methods, and results of scaling-up and institutionalizing a quality assurance mechanism within the Free Maternity Program of the Ministry of Health of Ecuador; b) Explore associations between the degree of institutionalization achieved and the presence of reforms introduced by the Law, believed to be favorable to the QA institutionalization process; and c) Synthesize lessons learned that can be adapted and applied in other Latin American countries. The main research questions of the study were: a) Is it possible to achieve expansion of CQI through a decentralized intervention involving staff from provincial offices of the MOH (CQI facilitators), who replicate training sessions and locally support and monitor the work of quality improvement teams?; b) Which are the main factors that facilitate or constrain the application of the CQI model?; c) What is the model’s cost?; d) What are the results in terms of the extent of CQI expansion and quality improvement of healthcare?

Facilitating factors for this community-level scale up in 35 districts included strong government support, local champions, and a national policy on preventing postpartum hemorrhage (PPH). Challenges included a lack of a systematic scale-up strategy, limited communication of the PPH policy, a shift from a universal distribution policy to application of eligibility criteria, difficulties engaging remote traditional birth attendants, and implementation of a parallel M&E system. ABSTRACT Background: Mozambique has a high maternal mortality ratio, and postpartum hemorrhage (PPH) is a leading cause of maternal deaths. In 2015, the Mozambican Ministry of Health (MOH) commenced a program to distribute misoprostol at the community level in selected districts as a strategy to reduce PPH. This case study uses the ExpandNet/World Health Organization (WHO) scale-up framework to examine the planning, management, and outcomes of the early expansion phase of the scale-up of misoprostol for the prevention of PPH in 2 provinces in Mozambique. Methods: Qualitative semistructured interviews were conducted between February and October 2017 in 5 participating districts in 2 provinces. Participants included program stakeholders, health staff, community health workers (CHWs), and traditional birth attendants (TBAs). Interviews were analyzed using the ExpandNet/WHO framework alongside national policy and planning documents and notes from a 2017 national Ministry of Health maternal, newborn, and child health workshop. Outcomes were estimated using misoprostol coverage and access in 2017 for both provinces. Results: The study revealed a number of barriers and facilitators to scale-up. Facilitators included a supportive political and legal environment; a clear, credible, and relevant innovation; early expansion into some Ministry of Health systems and a strong network of CHWs and TBAs. Barriers included a reduction in reach due to a shift from universal distribution to application of eligibility criteria; fear of misdirecting misoprostol for abortion or labor induction; limited communication and understanding of the national PPH prevention strategy; inadequate monitoring and evaluation; challenges with logistics systems; and the inability to engage remote TBAs. Lower coverage was found in Inhambane province than Nampula province, possibly due to NGO support and political champions. Conclusion: This study identified the need for a formal review of the misoprostol program to identify adaptations and to develop a systematic scale-up strategy to guide national scale-up.

Objective:
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.

Kangaroo Mother Care (KMC) is enjoying growing support from ministries of health, international development partners, health professionals, and families. Recent and established initiatives, such as the Every Newborn Action Plan, Helping Babies Survive, KMC Acceleration Partnership, and International Network in Kangaroo Mother Care, combined with a growing evidence base, documentation on scale-up challenges and solutions [1,2], and endorsement by the World Health Organization [3,4], have created favorable conditions for KMC scale-up in many countries. Proliferation of hospital KMC units is often displayed as a proud marker of progress – but how real is the progress we are making? What does it really mean to scale-up KMC? As a global community, we may be falling short on our efforts to scale effective KMC due to inadvertent conceptualization of KMC as a unit or place within the hospital, rather than a set of foundational care practices for premature infants. While there is wide variation in KMC practice in low-income settings, it is all too frequent that KMC may only be initiated a few days before discharge, in a step-down unit. Such practice misses the opportunity to provide this potentially life-saving intervention to babies who would benefit from and could be safely cared for using KMC practices. Current WHO guidelines recommend KMC for “stabilized” babies <2000g in hospital, but does not define “stabilized.” We contend that in many low-resource facility settings, small babies may be safely cared for using KMC practices while receiving oxygen, intravenous antibiotics, and some advanced care, therefore capturing the time of optimal benefit to save their lives through improved thermal care and breastfeeding. If KMC is conceptualized and operationalized as a care practice in conjunction with other care that may be required for the preterm newborn (eg, intravenous antibiotics, oxygen, feeding assistance) scaling up will save many lives. But if we fall into the trap of scaling up KMC as a place in a facility, far fewer lives will be saved, and we may thus have contributed to “empty scale-up” of KMC.

This paper presents the first published report of a national-level effort to implement the Integrated Management of Childhood Illness (IMCI) strategy at scale. IMCI was introduced in Peru in late 1996, the early implementation phase started in 1997, with the expansion phase starting in 1998. Here we report on a retrospective evaluation designed to describe and analyze the process of taking IMCI to scale in Peru, conducted as one of five studies within the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE) coordinated by the World Health Organization. Trained surveyors visited each of Peru\'s 34 districts, interviewed district health staff and reviewed district records. Findings show that IMCI was not institutionalized in Peru: it was implemented parallel to existing programmes to address acute respiratory infections and diarrhoea, sharing budget lines and management staff. The number of health workers trained in IMCI case management increased until 1999 and then decreased in 2000 and 2001, with overall coverage levels among doctors and nurses calculated to be 10.3%. Efforts to implement the community component of IMCI began with the training of community health workers in 2000, but expected synergies between health facility and community interventions were not realized because districts where clinical training was most intense were not those where community IMCI training was strongest. We summarize the constraints to scaling up IMCI, and examine both the methodological and policy implications of the findings. Few monitoring data were available to document IMCI implementation in Peru, limiting the potential of retrospective evaluations to contribute to programme improvement. Even basic indicators recommended for national monitoring could not be calculated at either district or national levels. The findings document weaknesses in the policy and programme supports for IMCI that would cripple any intervention delivered through the health service delivery system. The Ministry of Health in Peru is now working to address these weaknesses; other countries working to achieve high and equitable coverage with essential child survival interventions can learn from their experience. IMCI, scaling up, child health, Peru

Background
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.

Every year about 70% of neonatal deaths (almost 3 million) happen because effective yet simple interventions do not reach those most in need. Coverage of interventions is low, progress in scaling up is slow, and inequity is high, especially for skilled clinical interventions. Situations vary between and within countries, and there is no single solution to saving lives of newborn babies. To scale up neonatal care, two interlinked processes are required: a systematic, data-driven decision-making process, and a participatory, rights-based policy process. The first step is to assess the situation and create a policy environment conducive to neonatal health. The next step is to achieve optimum care of newborn infants within health system constraints; in the absence of strong clinical services, programmes can start with family and community care and outreach services. Addressing missed opportunities within the limitations of health systems, and integrating care of newborn children into existing programmes—eg, safe motherhood and integrated management of child survival initiatives—reduces deaths at a low marginal cost. Scaling up of clinical care is a challenge but necessary if maximum effect and equity are to be achieved in neonatal health, and maternal deaths are to be reduced. This step involves systematically strengthening supply of, and demand for, services. Such a phased programmatic implementation builds momentum by reaching achievable targets early on, while building stronger health systems over the longer term. Purposeful orientation towards the poor is vital. Monitoring progress and effect is essential to refining strategies. National aims to reduce neonatal deaths should be set, and interventions incorporated into national plans and existing programmes.

Background:
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.

Background
Quick scaling-up of innovative and promising interventions in health systems of low and middle-income countries to rapidly achieve population level benefits is a key challenge. While there is consensus on the need for rigorous scientific evidence on effectiveness of interventions before considering scale-up, there can be significant time lag for the want of gold-standard evidence. The Safe Childbirth Checklist (SCC) programme in India, demonstrated how an innovation was robustly evaluated and scaled up nationally, within a short span of time. In this narrative review, we describe the strategies discussed in various published scale-up frameworks and map them against the strategies adopted by the SCC programme to identify accelerators which facilitated its rapid scale up.

Methods
The narrative review – done from May to June 2017 - involved keyword searches of electronic databases of PubMed, Ovid Medline and Google Scholar. It included the key words ‘pilot’, ‘health innovations’, ‘scale-up’, ‘replication’, ‘expansion’, ‘increased coverage’, ‘conceptual models for scale-up’, ‘frame-works for scale-up’, ‘evidence for scale-up’ in the title of publications,. This search was limited to publications in English after the year 1995. We used snowball sampling approach (by referring to bibliographies of shortlisted publications) to identify additional publications related to scale-up. We then screened the identified publications independently and relevant publications that discussed attributes for a conceptual model for scale-up of public health interventions in low and middle-income countries were shortlisted. We then mapped the strategies we used in SCC program scale up against those described in the shortlisted frameworks to identify seven accelerators which facilitated rapid scale up.

Results
The identified accelerators were: testing the intervention in real world, resource constrained settings; using an appropriate and time sensitive research design; testing the intervention at substantial scale and in diverse settings; using an adaptive and iterative prototyping approach for implementation; sharing data and evidence with key stakeholders on an ongoing basis; targeting bridge resources through strategic engagement of stakeholders and timely integration of scale-up plans with annual planning and budgeting cycles and systems.

Conclusion
These accelerators will complement current frameworks and provide guidance to future scale-up initiatives in India and elsewhere.

Since 2008, the USAID Bureau for Global Health\'s flagship Maternal and Child Health Integrated Program (MCHIP) has worked in more than 50 developing countries in Africa, Asia, Latin America, and the Caribbean to improve the health of women and children. MCHIP has worked with USAID Missions, governments, nongovernmental organizations, local communities, and partner agencies in over 50 developing countries to assist in the scale up of high impact interventions in reproductive, maternal, newborn, and child health (RMNCH), one of MCHIP’s objectives. This brief summarizes the results of this scale up experience and the lessons learned, mainly based on 18 case studies of six high-impact RMNCH interventions in 14 countries supported by MCHIP over the life of the project (Larson et al. 2014). It also includes preliminary learning from two in-depth country studies and several studies of the scaling-up experience done by MCHIP technical teams for individual interventions they supported. The review analyzes the elements and strategies of the country scale up experiences and shows outcomes in institutionalizing and expanding the coverage of the interventions. It draws conclusions on lessons learned that could be applicable to other programs.

In 2003, the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), in partnership with the Bangladesh Ministry of Health and Family Welfare (MOHFW) and the private sector embarked on a national exercise to scale up zinc treatment of childhood diarrhoea as an adjunct to oral rehydration solution (ORS). Private sector participation included national associations representing licensed and unlicensed health care providers, a local pharmaceutical laboratory, a marketing agency and a technology transfer from the European patent holder of the dispersible zinc tablet formulation promoted in the scale-up campaign. This project was a response to several years of research in the preceding decade demonstrating that zinc supplementation during a diarrhoeal illness episode significantly reduces illness severity and duration as well as prevents subsequent morbidity and mortality. It has been estimated that zinc treatment has the potential to annually save nearly 400 000 under-5 lives, thus significantly impacting on Millennium Development Goal #4. This paper summarizes the primary coverage outcomes of the Scaling Up of Zinc in Early Childhood (SUZY) Project into its third year (December 2006 to October 2009). These results are assessed in relation to the Project’s theoretical foundations and the performance framework that was jointly planned and implemented through a public–private partnership. The scale-up campaign encountered numerous constraints, but also benefited from several facilitating factors which are summarized under an assessment framework developed to identify barriers and better promote the scaling up of key health interventions in low- and middle-income countries. The lessons learned are described with the intent that this will contribute to the more effective scale-up of life-saving interventions that will reach those in greatest need. Zinc treatment, scaling up, diarrhoea, Bangladesh, monitoring, mass media, promotion

This critical volume combines theoretical and empirical work across disciplines to explore what threatens scalability—and what enables it—in the early childhood field. Authors and editors provide specific recommendations to help professionals refine and apply the science of scaling in their programs, research, and decision making. Written by leading experts in early childhood, economics, psychology, public health, philanthropy, and more, chapters and commentaries shine light on how to effectively use experimental insights for policy purposes. The result is a comprehensive and forward-thinking guide to the challenges and possibilities of effective scaling in early childhood and beyond. Essential reading for researchers, practitioners, funders, and policy makers alike, this book raises vital questions and provides a vision for the long-term journey to scalable evidence.

The UK Department for International Development’s strategy on reducing maternal deaths highlights the benefits to maternal and newborn health of increasing skilled attendance. This report, compiled under the umbrella of the Partnership Safe Motherhood and Newborn Health, provides a synthesis of the evidence for the drive towards ‘skilled attendance for all’ and suggests steps that need to be taken to achieve this vision. Skilled attendant – A joint WHO/ICM/FIGO statement, endorsed by UNFPA and the World Bank defines a skilled attendant as ‘an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns’ (WHO 2004a). Skilled attendance – skilled attendance has been described as a partnership of skilled attendants AND an enabling environment of equipment, supplies, drugs and transport for referral to EmOC. The political, policy and socio-cultural environment can also enable or prevent ‘skilled attendance’ (Graham et al 2001). Experiences drawn from retrospective reviews of the interventions taken in countries that have reduced maternal mortality underpin the recommendation for investment in skilled attendants. Professionalisation of delivery care, usually by midwives, was a common factor in reviews of maternal mortality reduction in Europe during the late 1800’s and early 1900’s, in Sri Lanka and Malaysia since the 1950s, and in the more recent examples that span from Honduras to Egypt and Indonesia. These historical reviews are complemented by epidemiological studies, evaluations of intervention programmes and data modelling. Although none provide ‘gold standard’ evidence, valuable lessons to guide programme design and implementation can be drawn. These include: The development of skilled attendants and referral/emergency obstetric care delivery systems that are not competing alternatives but complementary strategies. Training of skilled attendants needs to be competency based, prioritise both clinical and interpersonal skills development, and be provided by skilled trainers. This is also essential for retraining and supportive supervision, where Professional Associations can play a key role. Production of skilled attendants must go hand in hand with improvements to the human resource management systems that impact on deployment, motivation and retention. Plans for training and deploying skilled attendants must take account of the need to ensure availability of, and access to, both midwifery and obstetric skills. Achieving skilled attendance for all requires attention to the political, social and legal actions that address women’s human rights; Equity concerns must be central to policy development and implementation strategies if provision of skilled attendance is to impact on the health outcomes of poor people.

This guide is for those supporting a systematic process of scale-up. Although the process can be managed successfully in various ways, we wrote this guide specifically with the perspective that there is a “scale-up coordinator” or scale-up manager. The concept for this figure is based on that used by the United States Agency for International Development’s (USAID’s) Center for Innovation and Impact (CII), who calls this person an “Uptake Coordinator” or “Product Manager.” It is described in the text box. CII, in turn, adapted this idea from the successful experiences of the Chlorhexidine (CHX) Work Group and the US pharmaceutical industry which often employs product managers to facilitate the rollout of a new drug or vaccine and see it through to rapid and widespread use. We generalize the concept to include scale-up of a service or approach. In global health, we feel that having a specific person in charge of the various processes and tasks is critical, because there are needs for coordination that span across various roles and touch on multiple routine systems, multiple Ministry of Health (MOH) departments, other public sector institutions, various partner agencies, and private sector partners. Someone supporting scale-up needs the scope and authority to bridge these divides. In order to be effective, this person must juggle various types of activities including technical and management roles. In the experiences used illustratively in this guide, the scale-up coordinator was someone working in the country office of an agency giving technical support to country-led MOH scale-up efforts, but with the right terms of reference and level of authority, this person could also be someone within the government structure itself.

Since 2010, the MAMI Special Interest Group (MAMI SIG) has developed into a dynamic community of committed individuals and organisations across nutrition and health. To address the urgent need and make the most of opportunities, momentum and demand, the MAMI SIG was scaled up into a MAMI Global Network in late 2020. In the MAMI Global Network Strategy 2021-25, we describe the MAMI Global Network’s five-year aim, mission, and strategy on MAMI to achieve transparency, to help focus activities, and to enable us all to contribute and engage in collective, coherent action in achieving a shared 2030 vision.

Implementation science is the study of the process of implementing programs and practices that have some evidence from the research field to suggest they are worth replicating. It is the study of how a practice that is evidence-based or evidence-informed gets translated to different, more diverse contexts in the real world. In this way, effective implementation bridges the gap between science and practice. There is a growing body of research looking at the processes and core components of implementing evidence-based practices in different settings and, especially, at what it takes to move an evidence-based practice from the laboratory to the field (Berkel, Mauricio, Schoenfelder, & Sandler, 2010; Durlak & Dupre, 2008; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Meyers, Durlak & Wandersman, 2012). However, historically, much of this research has focused primarily on adult services (Simpson, 2002) rather than on services for young children and evidence-based practices that support young children’s growth and development. The importance of implementation has come to the fore within the early childhood field in recent years because, increasingly, early childhood program developers are being asked both to prove their program’s efficacy before bringing it “to scale,” and to articulate which components of their model, or contexts in which the model is deployed, are essential for making the intervention a success. This is true of individual programs, such as discrete language and literacy interventions, as well as for larger, systems-level interventions, such as statewide initiatives to improve early childhood educators’ professional development, children’s school readiness, or child care quality. However, until now, the early childhood field has lacked a common framework and language with which to examine important implementation supports for successful initiatives. This research brief series seeks to provide early childhood researchers, program developers, and funders with an introduction to implementation frameworks and promising practices in implementation science, with the aim of facilitating their use in early care and education research and program evaluation.

Neonatal mortality accounts for 40% of under-five child mortality. Evidence-based interventions exist, but attention to implementation is recent. Nationally representative coverage data for these neonatal interventions are limited; therefore proximal measures of progress toward scale would be valuable for tracking change among countries and over time. We describe the process of selecting a set of benchmarks to assess scale up readiness or the degree to which health systems and national programmes are prepared to deliver interventions for newborn survival. A prioritization and consensus-building process was co-ordinated by the Saving Newborn Lives programme of Save the Children, resulting in selection of 27 benchmarks. These benchmarks are categorized into agenda setting (e.g. having a national newborn survival needs assessment); policy formulation (e.g. the national essential drugs list includes injectable antibiotics at primary care level); and policy implementation (e.g. standards for care of sick newborns exist at district hospital level). Benchmark data were collected by in-country stakeholders teams who filled out a standard form and provided evidence to support each benchmark achieved. Results are presented for nine countries at three time points: 2000, 2005 and 2010. By 2010, substantial improvement was documented in all selected countries, with three countries achieving over 75% of the benchmarks and an additional five countries achieving over 50% of the benchmarks. Progress on benchmark achievement was accelerated after 2005. The policy process was similar in all countries, but did not proceed in a linear fashion. These benchmarks are a novel method to assess readiness to scale up, an important construct along the pathway to scale for newborn care. Similar exercises may also be applicable to other global health issues. Maternal and child health, Millennium Development Goals, policy analysis, measurement, health systems, newborn, neonatal survival, scale up

Background
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.

Research conducted over the past decade has shown that community-based interventions can improve the survival and health of mothers and newborns in low- and middle-income countries. Interventions engaging women\\\'s groups in participatory learning and action meetings and other group activities, for example, have led to substantial increases in neonatal survival in high-mortality settings. Participatory interventions with women\\\'s groups work by providing a forum for communities to develop a common understanding of maternal and neonatal problems, as well as locally acceptable and sustainable strategies to address these. Potential partners for scaling up interventions with women\\\'s groups include government community health workers and volunteers, as well as organizations working with self-help groups. It is important to tailor scale-up efforts to local contexts, while retaining fidelity to the intervention, by ensuring that the mobilization of women\\\'s groups complements other local programs (e.g. home visits), and by providing capacity building for participatory learning and action methods across a range of nongovernmental organizations and government stakeholders. Research into scale-up mechanisms and effectiveness is needed to inform further implementation, and prospective surveillance of maternal and neonatal mortality in key scale-up sites can provide valuable data for measuring impact and for advocacy. There is a need for further research into the role of participatory interventions with women\\\'s groups to improve the quality of health services, health, and nutrition beyond the perinatal period, as well as the role of groups in influencing non-health issues, such as women\\\'s decision-making power.

Newborn health in Afghanistan is receiving increased attention, but reduction in newborn deaths there has not kept pace with declines in maternal and child mortality. Using the continuum of care and health systems building block frameworks, this article identifies, organizes and provides a synthesis of the available evidence on and gaps in coverage of care and health systems, programmes, policies and practices related to newborn health in Afghanistan. Newborn mortality in Afghanistan is related to the nation’s weak health system, itself associated with decades of conflict, low and uneven coverage of essential interventions, demand-side and cultural specificities, and compromised quality. A majority of deliveries still take place at home. Birth asphyxia, low birth weight, perinatal infections and poor post-natal care are responsible for many preventable newborn deaths. Though the situation has improved, there remain many opportunities to accelerate progress. Analyses conducted using the Lives Saved Tools suggest that an additional 10 405 newborn lives could be saved in Afghanistan in 5 years (2015–20), through reasonable increases in coverage of these high-impact interventions. A long-term vision and strong leadership are essential for the Ministry of Public Health to play an effective stewardship role in formulating related policy and strategy, setting standards and monitoring maternal and newborn services. Promotion of equitable access to health services, including health workforce planning, development and management, and the coordination of much-needed donor support are also imperative. Afghanistan, neonatal health, maternal and child health, health systems

Background:
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.

Background
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.

Breastfeeding (BF) promotion is one of the most cost-effective interventions to advance mother–child health. Evidence-based frameworks and models to promote the effective scale up and sustainability of BF programs are still lacking. A systematic review of peer-reviewed and gray literature reports was conducted to identify key barriers and facilitators for scale up of BF programs in low- and middle-income countries. The review identified BF programs located in 28 countries in Africa, Latin America and the Caribbean, and Asia. Study designs included case studies, qualitative studies, and observational quantitative studies. Only 1 randomized, controlled trial was identified. A total of 22 enabling factors and 15 barriers were mapped into a scale-up framework termed “AIDED” that was used to build the parsimonious breastfeeding gear model (BFGM). Analogous to a well-oiled engine, the BFGM indicates the need for several key “gears” to be working in synchrony and coordination. Evidence-based advocacy is needed to generate the necessary political will to enact legislation and policies to protect, promote, and support BF at the hospital and community levels. This political-policy axis in turn drives the resources needed to support workforce development, program delivery, and promotion. Research and evaluation are needed to sustain the decentralized program coordination “gear” required for goal setting and system feedback. The BFGM helps explain the different levels of performance in national BF outcomes in Mexico and Brazil. Empirical research is recommended to further test the usefulness of the AIDED framework and BFGM for global scaling up of BF programs. Topic: brazilbreast feeding developing countries latin america mexico mothers peer review statutes and laws coordination evidence-based practice community advocacy workforce

Building upon the World Health Organization's ExpandNet framework, 12 key principles of scale‐up have emerged from the implementation of maternal and newborn health interventions. These principles are illustrated by three case studies of scale up of high‐impact interventions: the Helping Babies Breathe initiative; pre‐service midwifery education in Afghanistan; and advanced distribution of misoprostol for self‐administration at home births to prevent postpartum hemorrhage. Program planners who seek to scale a maternal and/or newborn health intervention must ensure that: the necessary evidence and mechanisms for local ownership for the intervention are well‐established; the intervention is as simple and cost‐effective as possible; and the implementers and beneficiaries of the intervention are working in tandem to build institutional capacity at all levels and in consideration of all perspectives.

Background
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.

Background
There is a lack of literature on how to adapt new evidence-based interventions for maternal and newborn care into local health systems and policy for rapid scale-up, particularly for community-based interventions in low-income settings. The Uganda Newborn Study (UNEST) was a cluster randomised control trial to test a community-based care package which was rapidly taken up at national level. Understanding this process may help inform other studies looking to design and evaluate with scale-up in mind.

Objective
This study aimed to describe the process of using evidence to design a community-based maternal and newborn care package in rural eastern Uganda, and to determine the dissemination and advocacy approaches used to facilitate rapid policy change and national uptake.

Design
We reviewed UNEST project literature including meeting reports and minutes, supervision reports, and annual and midterm reports. National stakeholders, project and district staff were interviewed regarding their role in the study and perceptions of what contributed to uptake of the package under evaluation. Data related to UNEST formative research, study design, implementation and policy influence were extracted and analysed.

Results
An advisory committee of key players in development of maternal and newborn policies and programmes in Uganda was constituted from many agencies and disciplines. Baseline qualitative and quantitative data collection was done at district, community and facility level to examine applicability of aspects of a proposed newborn care package to the local setting. Data were summarised and presented to stakeholders to adapt the intervention that was ultimately tested. Quarterly monitoring of key activities and events around the interventions were used to further inform implementation. The UNEST training package, home visit schedule and behaviour change counselling materials were incorporated into the national Village Health Team and Integrated Community Case Management packages while the study was ongoing.

Conclusions
Designing interventions for national scale-up requires strategies and planning from the outset. Use of evidence alongside engagement of key stakeholders and targeted advocacy about the burden and potential solutions is important when adapting interventions to local health systems and communities. This approach has the potential to rapidly translate research into policy, but care must be taken not to exceed available evidence while seizing the policy opportunity.

The unveiling of the Sustainable Development Goals (SDGs) in 2015 signaled a new era in global health. This era is characterized by country leadership in scaling up high impact health interventions to meet national goals. The goal of a country-led scale-up is to achieve widespread and sustainable impact, requiring both highly effective coverage of the population in need and institutionalization of key systems supports to sustain these expanded services.

What we know: Child wasting levels remain extremely high in Pakistan and coverage of wasting treatment services is low.

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 we know: Child wasting levels remain extremely high in Pakistan and coverage of wasting treatment services is low.

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 we know: Maternal nutrition is a significant public health concern in Bangladesh that can lead to small-for-gestational age and pre-term newborns thus perpetuating the intergenerational cycle of malnutrition.

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.

In partnership with UNICEF regional office for South Asia, ENN produced a special edition of Field Exchange (issue 63) in October 2020 that focused on child wasting in South Asia. The edition aimed to increase the understanding of child wasting in South Asia and identify the challenges and opportunites to support advocacy efforts and inform policy, programme and research priorities.

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.

Background:
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.

Despite consensus on actions to improve nutrition globally, less is known about how to operationalize the right mix of actions—nutrition-specific and nutrition-sensitive—equitably, at scale, in different contexts. This review draws on a large scaling-up literature search and 4 case studies of large-scale nutrition programs with proven impact to synthesize critical elements for impact at scale. Nine elements emerged as central: 1) having a clear vision or goal for impact; 2) intervention characteristics; 3) an enabling organizational context for scaling up; 4) establishing drivers such as catalysts, champions, systemwide ownership, and incentives; 5) choosing contextually relevant strategies and pathways for scaling up, 6) building operational and strategic capacities; 7) ensuring adequacy, stability, and flexibility of financing; 8) ensuring adequate governance structures and systems; and 9) embedding mechanisms for monitoring, learning, and accountability. Translating current political commitment to large-scale impact on nutrition will require robust attention to these elements.

What we know: Despite falls in the prevalence of stunting in children, wasting remains a persistent problem in Nepal, a country prone to emergencies.

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.

While all eyes are on Lombardy, Madrid, New York and Wuhan, what do we know about the impact of COVID-19 on the rural poor and on food security in developing countries? How can the impact of the crisis be moderated? What positive breakthroughs could be provoked by this shock to move us into a better “new normal”? What can donors and implementing organizations do to support low- and middle-income countries during and beyond this crisis?

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.

The individual and institutional capacities required for the prevention and reduction of nutritional insecurity and hunger in lesser-developed countries as the twenty-first century approaches are identified in this book. Household nutritional "security" can be defined as the successful The essays in this book champion the idea of increasing, or scaling up, grass roots operations to provide nutritional security, while scaling down the efforts of national and international institutions. Scaling up involves strengthening local capacities to improve and expand upon current successful programs by building upon existing local culture and organizations. This, in turn, enables the programs to strengthen relationships with national governments, international bilateral/multilateral donors, as well as non-governmental organizations. Scaling down concerns the ways and means by which these various organizations encourage and complement the local development. Therefore, as local capacities are scaled up, the national/international control over decisions and functions is, ideally, scaled down. The volume also directly addresses the resultant complication: how to create programs that are both culturally specific and that will flourish well into the future.

This book addresses the broader questions of how both the content and the context of public policy affect its implementation. Through a series of case studies from Mexico, Peru, Brazil, Colombia, Zambia, Kenya, and India, ten scholars here demonstrate that numerous factors intervene between the statement of policy goals and their actual achievement in society.

This policy brief has two main purposes. The first is to provide an outline of the emerging framework of key considerations, principles and priorities for action to address undernutrition. The second is to mobilize support for increased investment in a set of nutrition interventions across different sectors. Thus, the intended audience is principally policymakers and opinion leaders, rather than nutrition specialists. The main elements of the framework for action are: ❑ Start from the principle that what ultimately matters is what happens at the country level. Individual country nutrition strategies and programmes, while drawing on international evidence of good practice, must be country-“owned” and built on the country’s specific needs and capacities. ❑ Sharply scale up evidence-based cost-effective interventions to prevent and treat undernutrition, with highest priority to the minus 9 to 24 month window of opportunity where we get the highest returns from investments. (See Table 1 in Section 4). A conservative global estimate of financing needs for these interventions is $10+ billion per year. ❑ Take a multi-sectoral approach that includes integrating nutrition in related sectors and using indicators of undernutrition as one of the key measures of overall progress in these sectors. The closest actionable links are to food security (including agriculture), social protection (including emergency relief) and health (including maternal and child health care, immunisation and family planning). There are also important links to education, water-supply and sanitation as well as to cross-cutting issues like gender equality, governance (including accountability and corruption), and state fragility. ❑ Provide substantially scaled up domestic and external assistance for countryowned nutrition programmes and capacity. To that end ensure that nutrition is explicitly supported in global as well as national initiatives for food security, social protection and health, and that external assistance follows the agreed principles of aid effectiveness of the Paris Declaration and the Accra Agenda for Action. Support major efforts at the national and global levels for strengthening the evidence base —through better data, monitoring and evaluation, and research—and, importantly, for advocacy.

Scaling of innovations is a key requirement for addressing societal challenges in sectors such as agriculture. Research for development (R4D) programs, projects and other interventions struggle to make innovations go to scale. Current conceptualizations of scaling are often too simplistic and narrow, and more systemic and multidimensional perspectives, frameworks and measures are needed. There is a gap between new complexity-aware scientific theories and perspectives on innovation, and practical tools and approaches that can improve strategic and operational decision-making in R4D interventions that aim to scale innovations. This chapter aims to bridge the gap by presenting the key concepts and measures of Scaling Readiness. Scaling Readiness is an approach that encourages critical reflection on how ready innovations are for scaling in a particular context for achieving a particular goal and what appropriate actions could accelerate or enhance scaling as a means to realize development outcomes. Scaling Readiness provides action-oriented decision support for (1) characterizing the innovation and innovation system; (2) diagnosing the current readiness and use of innovations as a proxy for their impact potential at scale; (3) developing strategies to overcome bottlenecks for scaling; (4) facilitating and negotiating multi-stakeholder innovation and scaling processes; and (5) navigating and monitoring the implementation process to allow for adaptive management. This chapter explains how Scaling Readiness supported the development and implementation of scaling strategies under the CGIAR Research Program on Roots, Tubers and Banana (RTB) in two distinct ways. First it describes how Scaling Readiness informed the design and management of the RTB Scaling Fund; a CGIAR RTB instrument for identifying and nurturing scaling ready RTB innovations. Second, it provides a case study of how Scaling Readiness was applied in one of the Scaling Fund projects to develop, implement and monitor strategies for scaling a Cassava Flash Dryer innovation in different countries in Latin America and Africa. The chapter concludes with a reflection and recommendations for the further improvement and use of Scaling Readiness in the R4D sector.

In the lead up to the 2019 SUN Global Gathering, ENN developed a series of synthesis papers unpacking key themes within Field Exchange and Nutrition Exchange during the last four years of the SUN KM project.

The individual and institutional capacities required for the prevention and reduction of nutritional insecurity and hunger in lesser-developed countries as the twenty-first century approaches are identified in this book. Household nutritional \"security\" can be defined as the successful The essays in this book champion the idea of increasing, or scaling up, grass roots operations to provide nutritional security, while scaling down the efforts of national and international institutions. Scaling up involves strengthening local capacities to improve and expand upon current successful programs by building upon existing local culture and organizations. This, in turn, enables the programs to strengthen relationships with national governments, international bilateral/multilateral donors, as well as non-governmental organizations. Scaling down concerns the ways and means by which these various organizations encourage and complement the local development. Therefore, as local capacities are scaled up, the national/international control over decisions and functions is, ideally, scaled down. The volume also directly addresses the resultant complication: how to create programs that are both culturally specific and that will flourish well into the future.

There are nearly 800 million people who suffer from chronic hunger1 and two billion who suffer from micronutrient deficiency in the world today2. A projected 702 million people still live in extreme poverty3. Much of this poverty, hunger and malnutrition is concentrated in rural areas in developing countries, where the majority of people rely on agriculture for their livelihoods. These challenges are likely to worsen in the years to come: the global population is expected to swell from 7.3 to 8.5 billion by 2030, and again to 9.7 billion by 20504, placing unprecedented pressure on food systems. Rising incomes will further increase demand for food—particularly foods, such as meat, that require more resources to produce. These changes, together with widespread environmental shifts and variability, will exert increasing pressure on the natural resources on which food production relies.

Food shortage, global food supply. The individual and institutional capacities required for the prevention and reduction of nutritional insecurity and hunger in lesser-developed countries as the twenty-first century approaches are identified in this book. Household nutritional \"security\" can be defined as the successful The essays in this book champion the idea of increasing, or scaling up, grass roots operations to provide nutritional security, while scaling down the efforts of national and international institutions. Scaling up involves strengthening local capacities to improve and expand upon current successful programs by building upon existing local culture and organizations. This, in turn, enables the programs to strengthen relationships with national governments, international bilateral/multilateral donors, as well as non-governmental organizations. Scaling down concerns the ways and means by which these various organizations encourage and complement the local development. Therefore, as local capacities are scaled up, the national/international control over decisions and functions is, ideally, scaled down. The volume also directly addresses the resultant complication: how to create programs that are both culturally specific and that will flourish well into the future.

A countrywide initiative, the ICDS programme is India’s primary response to addressing child malnutrition, but has had mixed success on the state of malnutrition in India. This article reviews the ICDS from the perspective of a scaling-up management framework and analyses aspects of design, advocacy, implementation and monitoring in the scaling-up of ICDS. Universalisation of ICDS with quality is well within the means of government and recent advocacy has resulted in increased funding; the scaling-up of ICDS is challenging. Successful scaling-up of ICDS requires the implementation of a multicomponent model, demanding a high level of quality and performance, coordination and convergence in the face of varying and limited management and technical capacity, poor governance environments, and little experience of engaging communities. Success in addressing these constraints is possible but attention to detail is critical and lessons should be adapted to suit local context.

Background
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

In many low- and middle-income countries, the challenges of scaling up successful localized projects to achieve national coverage are well recognized.1 However, because of the widely acknowledged success of national efforts to scale up interventions to prevent and control human immunodeficiency virus (HIV) infection, the disease is now largely managed as a chronic condition. The shift means that lessons from the HIV experience may be transferable to the rollout and scale-up of effective interventions for noncommunicable diseases in low- and middle-income countries.2 The scale-up of noncommunicable disease interventions is particularly important because coverage is still modest and the evidence base for implementation in low- and middle-income countries remains very limited.3

WHO’s best buys for reducing noncommunicable diseases in low-resource settings suggest several such interventions. The interventions include measures to improve tobacco control, increasing public awareness of the health benefits of physical activity, multidrug therapy for people at high risk of cardiovascular disease and the screening and treatment of cervical cancer.3 Low- and middle-income countries need to rapidly disseminate and implement effective noncommunicable disease interventions at a national scale, often in contexts of low resources and capacity. The risk of premature death (that is, of people younger than 70 years) from the four major noncommunicable diseases (cardiovascular diseases, cancers, chronic respiratory diseases and diabetes) decreased by 25.4% in high-income countries and by 24.4% in upper-middle-income countries between 2000 and 2015. However, such mortality only reduced by 7.8% in lower-middle-income countries and increased by 6.0% in low-income countries.4

Lack of context-specific evidence to underpin adaptation and implementation of best buys in low-income and lower-middle-income countries exacerbates this difference, as the bulk of research evidence on innovations to address noncommunicable diseases is from high-income countries.3 Despite limited evidence and capacity for adaptation of these best-buy interventions in low-resource settings, policy-makers and implementers in many low- and middle-income countries are expected to adapt and implement interventions from high-income countries and to move from pilot to implementation at scale. Nonetheless, some of the models of service delivery that have enabled the delivery of long-term care at scale may be transferable from HIV intervention scale-up to noncommunicable disease interventions. Lessons from the HIV experience, relevant to governance, financing, human resources, service delivery, products and technologies, information systems and community mobilization, and their potential applications to noncommunicable diseases are summarized in Table 1.

Background
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.

What Works: Clinical Evidence and International Guidance Three randomized controlled trials completed in South Africa, Kenya and Uganda during 2005 to 2007 demonstrated that male circumcision (MC) performed by trained medical professionals is safe and can reduce men’s risk of acquiring HIV through vaginal sex by approximately 60 percent.1-3 In light of these findings, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) convened a technical consultation in 2007 on MC for HIV prevention. The consultation recommended that geographic areas with high HIV prevalence, driven predominantly by heterosexual sex, and low MC rates immediately integrate MC services as an additional component of existing comprehensive HIV prevention strategies.4 The international community recommended urgent action because modeling studies revealed that to have an immediate impact on the epidemic, countries would need to increase MC prevalence to 80 percent within five years.5 Why Male Circumcision Is Underutilized A review of acceptability studies across nine sub-Saharan African countries showed that the most common barriers to MC among men and women are fear of pain, culture and religion, cost and time away from work, and concerns about safety.6 Yet the review also revealed a number of facilitating factors and that a high proportion of men and women in non-circumcising populations favored MC when associated with a protective effect against HIV. Even if acceptability is likely to be high enough to have a significant impact on the epidemic,6 health systems barriers must be addressed to meet increased demand for MC services. Barriers to MC at the health systems level include unavailability of trained health staff, lack of instruments and supplies, and inadequate service delivery.7 Absent or ambiguous health policies and lack of government commitment to adding MC to the existing HIV prevention strategy must also be addressed.

It is estimated that there are currently over 36 million people living with HIV/AIDS globally and in 1999, 5.3 million individuals were newly infected with the virus.1 The organisations currently addressing this rapid and devastating spread of the pandemic clearly are not operating at sufficient scale or with enough impact to stem its progress. The areas of the globe where 95 per cent of those living with HIV reside, and which is experiencing the fastest and most relentless growth of the epidemic, are broadly defined as developing countries. These are the very countries that are least able to afford to ensure broad and equitable access to the new anti-retroviral therapies against HIV/AIDS and treatments for opportunistic infections, or to provide care and support for those with HIV. Thus there is an urgent moral dimension to the struggle to enlarge the scale of HIV/AIDS activities. AIDS activities initiated by non-governmental organisations (NGOs) have been highly influential on thinking and strategies found within the HIV/AIDS sector. Yet despite their proliferation, NGOs often experience particular difficulties in increasing the scale of their activities to reach larger numbers of people, to have an impact at levels higher than the “community” and to address the broader social determinants of HIV/AIDS. Much of the pioneering contribution of NGOs active in HIV/AIDS to wider public debate and approaches in the sector has been spontaneous, as has often been the case in development, rather than a result of planned and deliberate strategy. Perceiving the urgent need for NGOs to expand the scale of their activities in the face of an escalating epidemic, Horizons and the International HIV/AIDS Alliance launched an initiative to examine the nature of the challenge to scale up in the context of HIV/AIDS internationally. This publication was prepared as part of this initiative and addresses the specific challenge of deliberately increasing the scale of HIV/AIDS prevention, care and support programmes in developing countries. It asks whether there are lessons from the broader literature on development which are of relevance to HIV/AIDS. An initial draft of this publication was presented to an international seminar convened as part of this project at which 12 NGOs from around the world presented their own experience of scaling up.2 Examples of increasing the scale of NGO activities in HIV/AIDS given here draw primarily on these case studies, presentations and comments at the seminar and relevant available published documentation. While the focus of the publication is on the activities of non-governmental organisations, it recognises that increasingly NGOs are engaging in partnerships with governments, academic institutions and other organisations in their quest to widen the impact of their activities.

In all countries where there is an HIV epidemic, certain subgroups of the population are at greater risk of HIV than others. These “key” populations include female sex workers (FSWs), men who have sex with men (MSM), transgender people, and people who inject drugs. While biological and behavioral factors contribute to their vulnerability to HIV, key populations around the world also face stigma, discrimination, and the threat of criminal prosecution, which pose serious barriers to their ability to access high-quality health care and other essential services. To have a sustained impact, any national HIV program must therefore ensure that interventions reach key populations and that services are available, accessible, acceptable, and affordable. Linkages Across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) is a five-year project to strengthen HIV prevention, diagnosis, treatment, and care among key populations. Its goal is to reduce HIV transmission among key populations and extend life for those who are HIV positive.1 It aims to accelerate the ability of partner governments, civil society organizations, and private sector health care service providers to plan, deliver, and optimize a package of comprehensive services, at scale, for HIV prevention, care, and treatment. This “LINKAGES cascade” of services is illustrated in Figure 1. It is aligned with the UNAIDS 90–90–90 targets2 — that by 2020, 90 percent of all people living with HIV will know their HIV status, 90 percent of people diagnosed with HIV will receive sustained antiretroviral therapy (ART), and 90 percent of people receiving ART will have viral suppression (meaning that HIV is at undetectable levels and there is effectively no risk of transmitting the virus to others).

In June 2014, the U.S. Agency for International Development awarded FHI 360 the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) project, a global cooperative agreement funded by the U.S. President's Emergency Plan for AIDS Relief. FHI 360 partners with Pact, IntraHealth International and the University of North Carolina at Chapel Hill to conduct a range of activities to reduce HIV transmission among key populations — sex workers, men who have sex with men, transgender persons and people who inject drugs — and to improve their enrollment and retention in care. Under LINKAGES, the FHI 360-led team accelerates the ability of governments, organizations working with key populations at risk of HIV and private-sector providers to plan and implement services that reduce HIV transmission among key populations and their sexual partners and extend the lives of those already living with HIV. Project activities enhance the HIV prevention and care cascade by increasing reach to key populations most at risk of acquiring or transmitting HIV, promoting routine HIV testing and counseling, and actively enrolling those with HIV into care and support interventions that enable them to remain in care. The project helps countries use and scale up evidence-based approaches to service provision; help key populations mobilize and advocate for changes in laws and the conduct of police, health care workers and policymakers; and work with governments to make programs sustainable for the long term.

Background:
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.

The UN has launched an initiative to place 3 million people in developing countries on antiretroviral AIDS treatment by end 2005 (the 3 by 5 target). Lessons for HIV/AIDS treatment scale-up emerge from recent experience with multidrug-resistant tuberculosis. Expansion of treatment for multidrug-resistant tuberculosis through the multipartner mechanism known as the Green Light Committee (GLC) has enabled gains in areas relevant to 3 by 5, including policy development, drug procurement, rational use of drugs, and the strengthening of health systems. The successes of the GLC and the obstacles it has encountered provide insights for building sustainable HIV/AIDS treatment programmes. Political momentum is building to scale up treatment programmes for HIV/AIDS in resource-limited settings. WHO has declared poor access to antiretroviral medicines for HIV/AIDS a global health emergency,1 and has joined with partners to pursue the 3 by 5 target: provision of treatment to 3 million people in developing countries by the end of 2005.2 To reach this target, supplies of safe, effective, affordable antiretrovirals need to be delivered to programmes in some of the poorest regions of the world, and the drugs must be used correctly by health-care workers and patients. As solutions are sought to hasten the scale-up of HIV/AIDS treatment, valuable insights could be gained from experience with another complex infectious disease, multidrug-resistant tuberculosis. This disease, which has an 18–24 month treatment period, has many similarities with HIV/AIDS: multidrug treatment that can have serious adverse events; prevention and treatment are components of a comprehensive management strategy; and the threat of drug resistance at individual and population levels. Furthermore, the diseases share many management requirements that are especially difficult to meet in regions where resources are scarce: long-term follow-up and assessment of patients; adequate supply, availability, and affordability of drugs and diagnostic tools; intensive patient support to ensure adherence to treatment; the need for laboratory monitoring; and the absence of evaluated, evidence-based policy for management in resource-limited settings coupled with the humanitarian imperative to provide access to treatment. In general, patients with multidrug-resistant tuberculosis in industrialised countries receive treatment with second-line drugs. However, until recently such treatment was not widely implemented in developing countries for reasons including: high costs (up to US$20000 perperson for some treatment regimens); long duration of treatment; the possibility of serious adverse events; the potential for further development of drug resistance; the focus on prevention rather than treatment of the disease; and the intensive laboratory monitoring purportedly required for successful treatment.

Background
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.

Background
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.

Background:
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.

Background
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.

Background
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.

Introduction:
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.

Background
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.

Malaria is the largest cause of health services attendance, hospital admissions and child deaths in Tanzania. At the Abuja Summit in April 2000 Tanzania committed itself to protect 60% of its population at high risk of malaria by 2005. The country is, therefore, determined to ensure that sustainable malaria control using insecticide-treated nets is carried out on a national scale. Case description Tanzania has been involved for two decades in the research process for developing insecticide-treated nets as a malaria control tool, from testing insecticides and net types, to assessing their efficacy and effectiveness, and exploring new ways of distribution. Since 2000, the emphasis has changed from a project approach to that of a concerted multi-stakeholder action for taking insecticide-treated nets to national scale (NATNETS). This means creating conditions that make insecticide-treated nets accessible and affordable to all those at risk of malaria in the country. This paper describes Tanzania's experience in (1) creating an enabling environment for insecticide-treated nets scale-up, (2) promoting the development of a commercial sector for insecticide-treated nets, and (3) targeting pregnant women with highly subsidized insecticide-treated nets through a national voucher scheme. As a result, nearly 2 million insecticide-treated nets and 2.2 million re-treatment kits were distributed in 2004. Conclusion National upscaling of insecticide-treated nets is possible when the programme is well designed, coordinated and supported by committed stakeholders; the Abuja target of protecting 60% of those at high risk is feasible, even for large endemic countries.

To mark the conclusion of our research, the EU-funded PERFORM2Scale project held a webinar - Lessons from PERFORM2Scale: Experiences of district-level management strengthening at scale. During the webinar we revealed the lessons learnt during our study and the potential applications of our approach to scaling-up. About PERFORM2Scale For the past five years our team - a consortium of research institutions from Africa and Europe - has been working on the scale-up of a Management Strengthening Intervention among district health management teams in Ghana, Malawi and Uganda. The intervention had previously been found to strengthen the capacity of district health managers, helping them to develop human resource management and health systems strategies to improve performance. Using an approach based on the ExpandNet model, PERFORM2Scale explored the potential for the intervention to be scaled-up for greater and longer-lasting impact.

Home-based care coverage in Africa is currently very low and likely to reduce drastically in the near future. This paper investigates the low coverage of home-based care programmes in Africa and uses two home-based care projects in Zambia as case studies. The very limited involvement of governments in the provision of home-based care services appears to be one of the main reasons behind the low coverage of home-based care in Africa. Governments therefore should provide some form of basic home-based care services and/or strengthen support to other institutions providing home-based care. In order to facilitate governments’ involvement in home-based care activities, an analysis of tasks performed by community nurses and volunteers is used to identify tasks that government, missionary or NGO employed nurses may be able to provide without, or with very limited, donor assistance. However, further research and development is needed to develop affordable, feasible and sustainable home care programmes that can be implemented by staff working in government, NGO and missionary health facilities. In addition, innovative strategies are required to establish effective partnerships between the NGO, missionary and government health facilities. Topic: hiv africa government home care services nurses tuberculosis zambia community partnerships nongovernmental organizations donors missionaries

Background
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.

The African Summit on Roll Back Malaria (Abuja, Nigeria, April 2000) resolved “to initiate appropriate and sustainable action to strengthen health systems to ensure that by the year 2005, at least 60% of those at risk of malaria particularly pregnant women and children under five years of age, benefit from the most suitable combination of personal and community protective measures such as insecticide-treated mosquito nets and other interventions which are accessible and affordable to prevent infection and suffering”. Since the first edition of this document in 2002, substantial resources have been raised through public: private partnerships for malaria interventions including ITNs through new funding mechanisms such as the Global Fund to Fight AIDS, Tuberculosis, Malaria, the World Bank’s Booster Programme, the US Presidential Malaria Initiative, and other new sources. Many of these investments are making it easier for countries to procure the necessary commodities for their malaria interventions. But relatively little investment has so far been made in the necessary health systems by which these goods can be effectively delivered to those in need. Hence effective coverage with ITNs remains low in many countries and meeting the Abuja and Millennium Development Goal (MDG) targets continues to be a formidable challenge for Africa where public health delivery systems are weakest. Strengthening health systems is not something that can be done quickly. Although increased funding for health system strengthening is now on the horizon for Africa, it is increasingly recognized that we cannot wait while the necessary sustainable systems are built. A two-pronged approach is needed to quickly reach high coverage, and then sustain high coverage.

Objectives
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.

Background:
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.

Background
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.

Background:
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.

Background: Scaling effective primary care innovations to benefit more people is of interest to decision makers. However, we know little about how promising innovations are being scaled "spontaneously," that is, without deliberate guidance.

Objective: We aim to observe, document, and analyze how, in real-life conditions, 1 primary care innovation spontaneously scales up across Quebec, Canada.

Methods: We will conduct a participative study using a descriptive single-case study. It will be guided by the McLean and Gargani principles for scaling and reported according to the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines. Informed by an integrated knowledge translation approach, our steering committee will include patient users throughout the project. Inspired by the Quebec College of Family Physician's "Dragons' Den" primary care program, we will identify a promising primary care innovation that is being or will be scaled spontaneously. We will interview the innovation team about their scaling experiences every month for 1 year. We will conduct interviews and focus groups with decision makers, health care providers, and end users in the innovation team and the target site about their experience of both scaling and receiving the scaled innovation and document meetings as nonparticipant observers. Interview transcripts and documentary data will be analyzed to (1) compare the spontaneous scaling plan and implementation with the McLean and Gargani principles for scaling and (2) determine how it was consistent with or diverged from the 4 McLean and Gargani guiding principles: justification, optimal scale, coordination, and dynamic evaluation.

Results: This study was funded in March 2020 by the Canadian Institutes of Health Research. Recruitment began in November 2023 and data collection began in December 2023. Results are expected to be published in the first quarter of 2024.

Conclusions: Our study will advance the science of scaling by providing practical evidence-based material about scaling health and social care innovations in real-world settings using the 4 guiding principles of McLean and Gargani.

The Bangladesh Rural Advancement Committee (BRAC) was established in 1972 as a small charitable group whose goal was to help reconstruct Bangladesh after the Liberation War. Following the social unrest of 1971 10 million refugees had returned to destroyed homes and crops. By the end of 1990 BRAC had organized 600000 of the poorest rural men and women into more than 10000 grassroots organizations in more than 9000 villages. As such by 1991 BRAC had grown into one of the largest indigenous nongovernmental organizations in the world. It is staffed by approximately 4250 regular employees and 4000 part-time primary school teachers with an annual budget of approximately US$20 million. Growing at the rate of 2000 new village groups and 100000 new members each year BRAC is evolving a strategy to lead its members to sustainable self-reliance. The authors explain how BRAC expanded its health program from home-based oral rehydration therapy to a full range of health and development activities focusing upon the poorest women in the community. The organization remains dynamic evolving to meet the needs of the people of Bangladesh.

A more rational distribution of tasks and responsibilities among health worker cadres has the potential to improve accessibility and cost effectiveness within health systems and to mitigate the impact of the health worker shortage. Nigeria’s national TSTS policy, approved in 2014, allows CHEWs) to provide long-acting family planning methods, including implants, in addition to short-acting, non-clinical methods, thus helping to ease the burden on facility-based providers and increasing accessibility to more rural areas.

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.

Liberia, a country plagued by recent civil war and extreme poverty, started its CHW program in 2016. Since then, the country has expanded its reach and today, about 70 percent of its 700,000 rural residents now have access to care.

To develop guidance for governments and partners seeking to scale community health worker programs, we developed a conceptual framework, collected observations from the scale-up efforts of 7 countries, workshopped the framework with technical groups and with country stakeholders, and reviewed literature in the areas of health and policy reform, change management, institutional development, health systems, and advocacy. We observed that successful scale-up is a complex process of institutional reform. Successful scale-up: (1) depends on a carefully choreographed, problem-driven political process; (2) requires that scaled program models are drawn from solutions that are available in a given health system context and aligned with the resources, capabilities, and commitments of key health sector stakeholders; and (3) emerges from iterative cycles of learning and improvement, rather than a single, linear scale-up effort. We identify stages of the reform process associated with each of these 3 findings: problem prioritization, coalition building, solution gathering, design, program readiness, launch, governance, and management and learning. The resulting Community Health Systems Reform Cycle can be used by government, donors, and nongovernmental partners to prioritize and design community health worker scale-up efforts, diagnose challenges or gaps in successful scale-up and integration, and coordinate the contributions of diverse stakeholders.

Background Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub–Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme. Methods We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme. Results N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts. Conclusions The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS.

Objectives.
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.

Scaling up task-shifting FP to CHEWs requires strong political and resource support for institutionalization within state systems. By working with the facilitators, addressing the barriers identified through this research, and implementing the key recommendations, the SMOH can expand the number of CHEWs trained, improve the quality of counseling and service provided, and increase the number of women with access to implants.

Scaling of projects from inception to establishment within the healthcare system is rarely formally reported. The Victorian Stroke Telemedicine (VST) programme provided a very useful opportunity to describe how rural hospitals in Victoria were able to access a network of Melbourne-based neurologists via telemedicine. The VST programme was initially piloted at one site in 2010 and has gradually expanded as a state-wide regional service operating with 16 hospitals in 2017. The aim of this paper is to summarise the factors that facilitated the state-wide transition of the VST programme. A naturalistic case-study was used and data were obtained from programme documents, e.g. minutes of governance committees, including the steering committee, the management committee and six working groups; operational and evaluation documentation, interviews and research field-notes taken by project staff. Thematic analysis was undertaken, with results presented in narrative form to provide a summary of the lived experience of developing and scaling the VST programme. The main success factors were attaining funding from various sources, identifying a clinical need and evidence-based solution, engaging stakeholders and facilitating co-design, including embedding the programme within policy, iterative evaluation including performing financial sustainability modelling, and conducting dissemination activities of the interim results, including promotion of early successes. Keywords Telemedicine, remote consultation, scaling

Background Canada has been referred to as the land of ‘perpetual pilot projects’. Effective innovations often remain small in scale, with limited impact on health systems. Several innovations have been developed in Canada to tackle important challenges such as poor access to services and excessive wait times – one of the most promising innovations that has been piloted is eConsult, which is a model of asynchronous communication that allows primary care providers to electronically consult with specialists regarding their patients’ medical issues. eConsult pilot projects have been shown to reduce wait times for specialist care, prevent unnecessary referrals and reduce health system costs. eConsult has been spread throughout Ontario as well as to certain regions in Manitoba, Quebec, and Newfoundland and Labrador. Our aim is to understand and support the scale-up process of eConsult in Ontario, Quebec, Manitoba, and Newfoundland and Labrador. Our specific objectives are to (1) describe the main components of eConsult relevant to the scale-up process in each province; (2) understand the eConsult scale-up process in each province and compare across provinces; (3) identify policy issues and strategies to scaling up eConsult in each province; and (4) foster cross-level and cross-jurisdictional learning on scaling up eConsult. Methods We will conduct a qualitative multiple case study to investigate the scaling up of eConsult in four Canadian provinces using a grey literature review, key stakeholder interviews (10 interviews/province), non-participant observations, focus groups and deliberative dialogues. We will identify the main components of eConsult to be scaled up using logic models (obj. 1). Scaling up processes will be analysed using strategies adapted from process research (obj. 2). Policy issues and strategies to scale-up eConsult will be analysed thematically (obj. 3). Finally, a symposium will foster pan-Canadian learning on the process of scaling up eConsult (obj. 4). Discussion This study will likely increase learning and support evidence-based policy-making across participating provinces and may improve the capacity for a pan-Canadian scale-up of eConsult, including in provinces where eConsult has not yet been implemented. This work is essential to inform how similar innovations can reshape our health systems in the evolving information age.

Background
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

Background
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.

Background Expanding healthcare innovations from the local to national level is a complex pursuit requiring careful assessment of all relevant factors. In this study (a component of a larger eConsult programme of research), we aimed to identify the key factors involved in the spread and scale-up of a successful regional eConsult model across Canada. Methods We conducted a constant comparative thematic analysis of stakeholder discussions captured during a full-day National eConsult Forum meeting held in Ottawa, Canada, on 11 December 2017. Sixty-four participants attended, representing provincial and territorial governments, national organisations, healthcare providers, researchers and patients. Proceedings were recorded, transcribed and underwent qualitative analysis using the Framework for Applied Policy Research. Results This study identified four main themes that were critical to support the intentional efforts to spread and scale-up eConsult across Canada, namely (1) identifying population care needs and access problems, (2) engaging stakeholders who were willing to roll up their sleeves and take action, (3) building on current strategies and policies, and (4) measuring and communicating outcomes. Conclusions Efforts to promote innovation in healthcare are more likely to succeed if they are based on an understanding of the forces that drive the spread and scale-up of innovation. Further research is needed to develop and strengthen the conceptual and applied foundations of the spread and scale-up of healthcare innovations, especially in the context of emergent learning health systems across Canada and beyond.

The mHealth Assessment and Planning for Scale (MAPS) Toolkit is a comprehensive self-assessment and planning guide designed to improve the capacity of projects to pursue strategies that increase their potential for scaling up and achieving long-term sustainability. MAPS is designed specifically for project managers and project teams who are already deploying an mHealth product, and who are aiming to increase the scale of impact. External parties seeking to understand the maturity and value of mHealth projects may also find value in using the Toolkit jointly with projects. The Toolkit covers six major areas (referred to as the “axes of scale”) that influence the scaling up of mHealth: Groundwork, Partnerships, Financial health, Technology & architecture, Operations, and Monitoring & evaluation. The axes of scale reflect the key concerns, activities and decisions that relate to these six areas. MAPS allows users to assess where projects stand in relation to each of the axes of scale, and to track progress as activities evolve and progress. The Toolkit will help project teams to identify areas that require further attention, and then to devise strategies to overcome any challenges or obstacles to progress. MAPS is designed to be used periodically at several time points throughout a project’s trajectory, guiding projects through an iterative process of thorough assessment, careful planning and targeted improvements. These steps facilitate successful scaling up of mHealth products.

The cocalero – the coca-growing campesino – has suffered greatly during the two generations of armed conflict in Colombia. Caught between the Colombian government, the guerrillas of the FARC and ELN, and narco-traffickers, the cocalero had little choice but to grow coca to provide livelihoods for their families. Because coca is an easy to grow and profitable crop, and because “customers” come to pick up the coca from the farmgate, campesinos have lost both their knowledge of farming and their understanding of markets. Billions of dollars and decades of effort by the Colombian Government, the United States, the United Nations and countless non-governmental organizations have failed to eradicate coca. While the 2016 Peace Accords sought to address the illicit crops through the creation of the Programa Nacional Integral de Sustitución de Cultivos Ilícitos (PNIS), errors and delays in its execution prevent the achievement of its objective to reduce coca farming. The successful eradication of coca depends on the development of legal and sustainable economic alternatives for the cocaleros. Research on successful illicit crop reduction programs indicates that development of economic alternatives must come first, only then followed by the eradication of illicit crops, a process done in concert with the communities that depend on coca for their livelihoods. Launched in 2015, OEF/PASO Colombia began serving ex-combatants to reincorporate them into Colombian society and help them learn new skills that would allow them to participate in the economy. Ongoing work has taught PASO that successful reincorporation is a fundamentally holistic work, requiring the cooperation of many stakeholders, among them, the neighboring campesinos who may or may not be growing coca. This experience laid the foundation for PASO’s Cash for Work (CFW) program in which 2,000 cocalero families are working to develop a viable path away from coca and toward other agricultural endeavors. Similar to PASO’s CFW program, many NGOs emphasize organizational strengthening, new economic opportunity development and community governance in their programs. However, in the decade that the University of Notre Dame’s Business on the Frontlines program has worked with two dozen partners around the world, including leading international humanitarian organizations, specialized NGOs, and local non-profits, our assessment is that PASO has created a unique approach to addressing such issues. PASO emphasizes the dignity and fellow humanity of all those they serve, thereby building trust, hope, and agency among participants. PASO emphasizes local solutions for local challenges, utilizing operational experts (extensionistas) to develop work plans jointly with the communities it serves, and then supports them in implementing those plans. PASO unabashedly embraces the market, working to commercialize the crops that communities can produce – further reinforcing a local approach, as the crops grown in mountainous geographies vary from those from the jungles of Putumayo. This is a difficult path for any individual campesino, and thus, PASO emphasizes the mutual support gained from a communal approach. Finally, PASO looks to create graduates of its programs, rather than beneficiaries who are reliant on the next NGO program. This report sets PASO’s approach to coca reduction into a historical context and differentiates it from other programs with similar objectives, thereby explaining why PASO’s CFW programs are seeing greater success. Nevertheless, the ongoing drug trade, the violence it fosters, and the thousands of remaining coca-growing campesinos stuck in the illicit economy directly threaten Colombia’s hopes for transformation toward peace. PASO’s successful Cash for Work program needs to be scaled up to address the needs of many more campesinos than the initial 2,000 families, in order that they may exit the illegal economy toward legal production. It stands to reason that more resources will be needed to do so. This report then proposes a model for scaling Cash for Work in a two-phased approach as well as identifies opportunities to improve current PASO operations.

The importance of scaling initiatives that promote environmental protection and conservation is almost universally recognized. But how is scaling best achieved? We empirically evaluated the relationship of a list of factors that have been postulated to facilitate successful scaling to the degree of scaling success achieved in 56 case studies from a variety of sectors. We identified 23 factors that are significantly associated with successful scaling, defined as self-replication: an innovation that is congruent with local sociocultural patterns, takes advantage of existing scaled infrastructure, and facilitates a paradigm shift; adequate resources and constituencies for scaling, secured from the start, drawn from both within and outside the system; pilot sites that reflect conditions at future sites rather than ideal conditions; clear and deliberate scaling expectations and strategy; capitalization on economies of scale; a project team that has a unifying vision, includes both individuals who helped design the innovation and members of the target audience, and empowers users with the requisite skills; target audiences that take ownership of the project; the provision of long-term support systems; ongoing learning about the factors influencing scaling; direct management of relevant supply and demand streams; targeted marketing and dissemination efforts; and the evaluation of scaling success indicators. We also explored correlations between these principles, and identified a group of principles that together explain nearly 40% of the variance in success: the provision of long-term support systems (or one of its surrogates: turning users into partners, a user organization with wide reach, and the empowerment of the target audience with requisite skills); resources mobilized from within and outside the system; user organizations that have the capacity to implement the innovation; innovations that are platform solutions and that provide rapid feedback; and pilot sites that have realistic conditions relative to future sites. Our results suggest that for scaling to be successful: (1) scaling must be considered at all stages of a project; (2) the context must be managed and barriers to scaling must be identified and removed and (3) deliberate attention must be paid to scaling methods, marketing and dissemination efforts, and long-term monitoring of scaling progress.

Research suggests that parenting programs are effective for preventing behavioral and emotional difficulties in children, but a lot more attention needs to be paid to issues of context and culture during the development, testing and implementation of these interventions. The views and needs of underserved and disenfranchised communities in the US and the Global South are often not taken into account for the development and testing of interventions. The successful implementation of evidence-based interventions for vulnerable children and families in underserved and marginalized communities requires careful consideration of how existing paradigms of prevention, evaluation, and implementation science impact issues of social justice and equity. This paper will describe how a team of parenting program researchers has been collaborating with their partners globally in generating local knowledge by balancing the need for rigorous scientific methods with issues of power. Authors from the U.S., Latin America, Africa and Southeast Asia draw on their experiences regarding challenges and successes with issues regarding study design and measurement, the transferability and adaptation of interventions, and the dissemination and implementation of different parenting interventions while placing communities at the center of their efforts through participatory methods. We describe innovative approaches that span the continuum of intervention development, adaptation, optimization, evaluation, implementation, and scale up of different parenting programs for vulnerable children and families across the world. We conclude by offering specific and pragmatic recommendations to increase access of culturally relevant and effective parenting programs in these communities.

WHO’s best buys for reducing noncommunicable diseases in low-resource settings suggest several such interventions. The interventions include measures to improve tobacco control, increasing public awareness of the health benefits of physical activity, multidrug therapy for people at high risk of cardiovascular disease and the screening and treatment of cervical cancer.3 Low- and middle-income countries need to rapidly disseminate and implement effective noncommunicable disease interventions at a national scale, often in contexts of low resources and capacity. The risk of premature death (that is, of people younger than 70 years) from the four major noncommunicable diseases (cardiovascular diseases, cancers, chronic respiratory diseases and diabetes) decreased by 25.4% in high-income countries and by 24.4% in upper-middle-income countries between 2000 and 2015. However, such mortality only reduced by 7.8% in lower-middle-income countries and increased by 6.0% in low-income countries.4

Lack of context-specific evidence to underpin adaptation and implementation of best buys in low-income and lower-middle-income countries exacerbates this difference, as the bulk of research evidence on innovations to address noncommunicable diseases is from high-income countries.3 Despite limited evidence and capacity for adaptation of these best-buy interventions in low-resource settings, policy-makers and implementers in many low- and middle-income countries are expected to adapt and implement interventions from high-income countries and to move from pilot to implementation at scale. Nonetheless, some of the models of service delivery that have enabled the delivery of long-term care at scale may be transferable from HIV intervention scale-up to noncommunicable disease interventions. Lessons from the HIV experience, relevant to governance, financing, human resources, service delivery, products and technologies, information systems and community mobilization, and their potential applications to noncommunicable diseases are summarized in Table 1.

Fragile states present one of the greatest challenges to global development and poverty reduction. Despite much new learning that has emerged from within the development community in recent years, understanding of how to address fragility remains modest. There is growing recognition that donor engagement in fragile states must look beyond the confines of the traditional aid effectiveness agenda if it is to achieve its intended objectives, which include statebuilding, meeting the needs of citizens, and managing risk more effectively. Current approaches are constrained by relying heavily on small-scale interventions, are weakened by poor coordination and volatility, and struggle to promote an appropriate role for the recipient state. Scaling up (i.e., the expansion, replication, adaption and sustaining of successful policies and programs in space and over time to reach a greater number of people) is highly relevant to fragile settings, both as an objective and as a strategic approach to development. As an objective, it reinforces the logic that the scale of the challenges in fragile states demands interventions that are commensurate in purpose and equal to the task. As a strategy, it encourages donors to identify and leverage successes, and to integrate institutional development more explicitly into projects and programs. In addition, scaling up can assist donors in addressing the priority areas of improved project design and implementation, sustainability and effective risk management. Successful scaling up in fragile states almost certainly occurs less often than is possible and does not always involve a systematic approach. Donors should therefore look to more systematically pursue scaling up in fragile states and evaluate their performance with specific reference to this objective. This can be done by incorporating relevant elements of a scaling up framework into operational policies, from strategy development through to program design and monitoring. Contrary to expectations, there are compelling examples of successful scaling up in fragile states. While the conditions prevailing in fragile states create serious obstacles in terms of “drivers” (the forces that push the scaling up process forward) and “spaces” (the opportunities that need to be created, or potential obstacles that need to be removed for interventions to grow), and in terms of the operational modalities of donors, these can be overcome through the careful 2 Global Economy and Development Program design and delivery of programs with a clear focus on creating scaling up pathways, and through close partnership and sustained engagement of governments, communities and foreign partners.

The first phase of the Scaling-up Action Research Project was undertaken to determine whether the current framework for community-driven development (CDD) projects can create the right conditions for such projects to evolve into programs that are sustained through normal resource transfer systems, so that poverty reduction activities are not forever dependent on government borrowing and NGOs. The concern with the donor/NGO approach is that it does not lead to sustainable change in how national poverty programs are implemented, and does nothing to promote the efficient use of public resources. CDD, by contrast, has been shown to be up to __?_ percent more efficient in the use of public resources, while at the same time fostering community empowerment and building the social capital necessary for poor communities to take an active part in their own development. In this context, scaling up refers to the incorporation of CDD principles into national poverty programs, and to CDD activities being sustained through permanent resource transfer mechanisms.

When monitoring and evaluation are in an organization’s DNA, as they are at SNEHA, it’s much easier to create partnerships with government agencies and NGOs. When we launched the Society for Nutrition, Education & Health Action (SNEHA) in 1999, we set out to empower women from Mumbai’s slums with the information and tools they desperately needed to build healthier families. The level of need was extraordinary, and one of us (Dr. Fernandez) had witnessed it first-hand, working for more than three decades at Mumbai’s busiest public hospital, where it was a daily struggle to save underweight and premature infants born to poor mothers with little or no basic health knowledge. Looking back to those early days, the idea of “achieving scale” was quite foreign to most of SNEHA’s leadership team; they were doctors and health providers. As Dr. Fernandez recalls, “Truthfully, I didn’t even know what an NGO was. When we got our first money, I remember asking, now what?” But a lot has changed. Today, SNEHA has a staff of roughly 380, operates in 12 of Mumbai’s 23 municipal wards, is a presence in six municipal corporations outside Mumbai, and has an annual budget of INR 16.26 crores ($2.45 million). Over our 17 years, we’ve served more than one million women and children across Mumbai. Scale is now something we talk about regularly. And along the way, we have learned that scale comes in a variety of ways: Evidence attracts funders who support growth and stretch; government programs and NGOs adopt proven approaches; and advocacy can lock in gains, providing strong roots from which to grow.

French and Bell explore the improvement of organizations through planned, systematic, long-range efforts focused on the organization\'s culture and its human and social processes. They present a concise but comprehensive exposition of the theory, practice and research related to organization development. The Fifth Edition reflects recent developments, advances and expansions, and research.

Discover Malcolm Gladwell's breakthrough debut and explore the science behind viral trends in business, marketing, and human behavior. The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire. Just as a single sick person can start an epidemic of the flu, so too can a small but precisely targeted push cause a fashion trend, the popularity of a new product, or a drop in the crime rate. This widely acclaimed bestseller, in which Malcolm Gladwell explores and brilliantly illuminates the tipping point phenomenon, is already changing the way people throughout the world think about selling products and disseminating ideas.

This paper describes the concept of an inclusive business ecosystem, and presents three structures companies can employ to strengthen these ecosystems. It is based on an analysis of 15 case examples that have been identified in a review of 170 documented efforts by companies to start and scale inclusive business models.

The global community has set itself the challenge of meeting the Millennium Development Goals (MDGs) by 2015 as a way to combat world poverty and hunger. In 2007, the halfway point, it is clear that many countries will not be able to meet the MDGs without undertaking significantly greater efforts. One constraint that needs to be overcome is that development interventions—projects, programs, policies—are all too often like small pebbles thrown into a big pond: they are limited in scale, short-lived, and therefore have little lasting impact. This may explain why so many studies have found that external aid has had weak or no development impact in the aggregate, even though many individual interventions have been successful in terms of their project- or program-specific goals. Confronted with the challenge of meeting the MDGs, the development community has recently begun to focus on the need to scale up interventions. Scaling up means taking successful projects, programs, or policies and expanding, adapting, and sustaining them in different ways over time for greater development impact. This emphasis on scaling up has emerged from concern over how to deploy and absorb the substantially increased levels of official development assistance that were promised by the wealthy countries at recent G8 summits. A fragmented aid architecture complicates this task; multilateral, bilateral, and private aid entities have multiplied, leading to many more—but smaller— aid projects and programs and increasing transaction costs for recipient countries. In response, some aid donors have started to move from project to program support, and in the Paris Declaration, official donors committed themselves to work together for better coordinated aid delivery. The current focus on scaling up is not entirely new, however. During the 1980s, as nongovernmental organizations (NGOs) increasingly began to engage in development activities, scaling up emerged as a challenge. NGO interventions were (and are) typically small in scale and often apply new approaches. Therefore, the question of how to replicate and scale up successful models gained prominence even then, especially in connection with participatory and community development approaches. Indeed, the current interest among philanthropic foundations and NGOs in how to scale up their interventions is an echo of these earlier concerns. In response to this increased focus on scaling up—and its increased urgency—this policy brief takes a comprehensive look at what the literature and experience have to say about whether and how to scale up development interventions.

Evidence from randomized evaluations is changing how we understand and address problems related to poverty. Policymakers, practitioners, and funders worldwide are increasingly applying this learning to social policies and programs. Over 540 million people have been reached by programs and policies that have been informed by evaluations by J-PAL affiliated researchers. Many more have benefitted from the several broader ways evidence can inform policy, outlined below. Well-designed randomized evaluations test theories and provide general insights about how programs designed to address poverty work. These insights, when combined with descriptive data and a deep understanding of the local context and institutions, provide useful guides for policy design. Strong partnerships between implementers, researchers, and donors are critical to leveraging evidence to inform policy.

A number of global development challenges do not seem to be solved by gradually changing or reforming current ways of production, consumption, transport or other systems. For years, actors in academia, policy and practice have been calling for more action on ‘transformational change’, meaning a change that is profound enough to shift societies, up to ‘the’ global one onto fundamentally different development pathways. The term ‘transformation’ is not only fashionable in describing new types of change interventions and new ways of intervening. It has also become a prerequisite for international funding.

People Centered Development: Contributions toward Theory and Planning Frameworks is an examination of the gradual shift from production centered development to human-centered development, with particular attention paid to the conceptual and theoretical frameworks of human-centered development. People Centered Development: Contributions toward Theory and Planning Frameworks will be of interest to those who seek both an historical perspective and a contemporary interpretation of the human-centered development movement. The book is divided into eight parts and is a collection of the work of multiple authors. The first part is an introduction by the editors and offers an outline of the book. Authors of the work included in part two \"... place the current human situation in a long-term evolutionary perspective. The basic argument they develop is that both the industrial and agricultural societies are in the midst of an important transition involving major changes in values, social structures, and modes of production...\". Toward that end, Alvin Toffler addresses third wave developments and the impact of Gandhi. George T. Lock Land discusses directionality in evolution while John Platt examines what he considers to be the greatest evolutionary jump in history. Part three offers strategies for coming to terms with life on a small planet. Kenneth Boulding examines the economics of the \"spaceship earth\". Garrett Hardin\'s famous discussion of \"The Tragedy of the Commons\" is chapter eight. A case study which examines the managing of the open-access resource of coastal fisheries, supports Hardin\'s assertions. Part four examines the relationship between competition and the dynamics of poverty. The relative merits of orthodox development economics and the dynamics of concentration and marginalization are examined. Izzedin Imam offers a discussion of peasant perceptions of famine which is followed by a consideration of the seasonal nature of poverty. Chapter thirteen offers a practical consideration of the previous two chapters with an examination of the survival, interdependence and competition among the Philippine rural poor. Simon Fass addresses the political economics of drinking water. The final two chapters of part four discuss the urban bias in world development and the dynamics of dependency and marginality. Part five is an examination of social learning and the nature of planning and begins with Edgar Dunn Jr.\'s estimation of the nature of social learning. This is followed by discussion of the learning process approach to rural development programming. The final chapter of this part addresses the nature of development and planning. Part six offers three chapters which address planning for equity and self-reliance. The first of these presents planning frameworks for people-centered development. The middle chapter presents a territorial approach to meeting basic needs which John Friedman terms \'agropolitan development\'. The final chapter of this part considers the self-reliant city. The penultimate part considers governance by the people and for the people with an opening chapter which examines the crisis of democratic governance. The second chapter discusses empowerment. Richard Nelson addresses organizational responses to public policy issues through the examination of the case of day-care. Grace Goodell offers a conservative perspective on political development and social welfare. The final two chapters of this part offer thoughts on the restructuring of the United States. The final part is David Korten\'s consideration of the steps necessary to move toward a framework for people-centered development. The text is carefully annotated and easy to read.

Inclusive business models can achieve only limited impact when isolated; only through replicating such models can the 4 billion people at the base of the pyramid be reached with goods, services, and economic opportunity. Years of experimentation has seen the emergence of successful inclusive business models, and it is time to build on what has been learned and multiply the impact of models that work.

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.

Development ministers and experts will meet at the Fourth High Level Forum on Aid Effectiveness in Busan, Korea, in November 2011 to assess their efforts to improve the impact of aid. A recent survey by the OECD shows that little progress has been made since they met in Accra in 2008 for their Third High Level Forum. The many good intentions to improve coordination among donors, to enhance the alignment of aid programs with the priorities of aid recipients, and to develop effective partnerships in practice have turned out to be difficult to implement. If anything, the challenge has become greater: the number of aid agencies keeps rising, as does the number of aid-supported projects, while average project size continues to drop. According to the OECD, more than half of the 90,000 official aid projects implemented annually are now well below $100,000 in size. With so many small interventions, most of them one-time, without links to each other, driven by the short-lived preferences of individual agencies and individuals in agencies, it is no surprise that the lofty goals of aid ministers go unrealized and that the cumulative impact of the many well-intentioned small aid projects is minimal at best. It doesn’t have to be that way. There are examples of successful development programs that have lifted millions of people out of poverty, have greatly improved health conditions and have generated new business and employment opportunities. Examples such as the Mexican government’s national program of cash transfers to poor households (“Progresa-Oportunidades”) which conditions assistance on whether children attend school and mothers take their infants for health check-ups; the multi-donor program to eradicate the deadly river-blindness disease in West-Africa; the community based microcredit and employment programs of Grameen Bank and BRAC in Bangladesh; the Chinese government’s program for the development of the loess plateau with support of the World Bank; or the program of rural poverty reduction in the highlands of Peru supported by the International Fund for Agricultural Development (IFAD) – these are just a few examples of cases where the impact of development programs has been at a scale such that it made a real and lasting difference in the lives of millions of people. And success at scale is also possible in fragile and conflict-affected states as a recent review by the Brookings Institution for the Australian aid agency AusAID has shown.

Scaling up the impact of interventions for maximum sustained development results should be a primary objective of international aid organizations. This article reports on a review of the African Development Bank’s (AfDB) country strategy papers (CSPs) from a scaling-up perspective. It concludes, based on a sample of strategy and supporting documents, that the AfDB’s CSPs do not focus systematically on scaling up the impact of the projects and programs that this multilateral development bank supports. This is not surprising, since the AfDB’s corporate strategy, policies, and processes do not explicitly focus on scaling up. However, the review also concludes that key elements of a scaling-up approach are found in the AfDB’s CSPs. If they were systematically applied across the board, AfDB could readily turn its CSPs into effective scaling-up strategies.

The path to scale is full of curves and bumps. It is difficult to develop generalisable principles or recommendations. In lieu of these, from the experiences that we observed over the course of this project, we identified five important issues that we think all organisations thinking about scale should address. Don’t jump to scaling up right away. Make sure you develop a deep appreciation of the problems and potential parts of the solution first. Maintain mechanisms for learning and refining even as you scale. It doesn’t hurt to have scale in mind from the beginning, but don’t rush through the preparation because you feel pressure to start showing results and growth. Scaling is as much about removing or “scaling down” social barriers as scaling up impactful activities. Consider all angles when planning your approach, including the barriers that your organisation may face in the process. Be pragmatic. To scale, you have to choose your priorities, opportunities and your battles wisely. Be flexible on everything, except those values that are absolutely essential to your goal. Your approach and potentially even your organisation will need to evolve. Prepare to reinvent yourself if necessary. October 2014 Page 9 Learn more There’s no avoiding the fact that relationships matter. From day one, take time to cultivate a network and build trust and rapport with key stakeholders. Relationships are just one component of effective intermediation; if your organisation lacks the bandwidth or interest for these activities, consider partnering up with someone who can. Most issues can’t be tackled overnight. If it were that easy, we’d all be out of a job! Take a long view—many social issues may take a generation to truly overcome. Focus on laying the groundwork and changing those things that can be changed now, to create new opportunities for change tomorrow. We learned a great deal over the past two years about how diverse organisations across South Asia think about and approach scale. These findings only begin to skim the surface of the deep wisdom left to be discovered. Historically relatively little research on these topics has focused on the global south, despite the known existence of organisations like BRAC, Gram Vikas, RSPN, Nidan and a2i with expertise on excelling at scale. We encourage others to join in these inquiries, as deepening the sector’s understanding of scale can accelerate progress in poverty reduction globally.

This is a collection of scholarly essays on state, society and politics in the Third World, with cases drawn from Africa, the Middle East, Asia, and Latin America. The introductory chapter outlines the theoretical approach of the contributors and the concluding chapter summarizes the importance of their studies and the contribution of the volume to general theory in comparative politics. The book is relevant to the growing state theory literature in the social sciences and it puts forward a state-in-society approach to the study of political development.

Why do some development programs succeed while so many others fail? What role do managerial and institutional innovations play in program performance? Dr. Paul\'s comparative analysis of six successful development programs selected from Asia, Africa, and Latin America provides important answers to these questions. The study shows that a clear focus on a single goal or service; decentralization; the use of network structures and beneficiary participation consistent with the complexity of the program environment; and highly adaptive planning, monitoring, and motivation processes are among the common features of the six successful programs. The design and orchestration of these and other elements were facilitated by the relative autonomy of the programs and by the continuity and commitment of their leadership. There is no dearth of studies of failure in the field of development, points out Dr. Paul, but studying failure does not necessarily lead to insights into the positive management actions and institutional innovations that have led to successful programs. This study, the first of its kind to focus on high performers, is unique in the lessons it offers on the strategic management of development programs.

The scaling up of development policies, practices and partnerships is a strategic challenge. The upgrading of development ambition from investment operations and country strategies to global policies would extrapolate a secular trend that has propelled the development business from the pioneering phase of projects conceived as “privileged particles of development”; to the neo-classical phase of macro-economic adjustment; to the advent of environmentally and socially sustainable development and most recently to the adoption of country based comprehensive development frameworks. Because the global economy is increasingly interconnected, the development enterprise must be reshaped to reflect shared objectives, distinct accountabilities and reciprocal obligations between rich and poor countries. Because development is a social transformation process, the development paradigm must become holistic. Because incentives matter, development metrics must be reconsidered to emphasize results. The universal endorsement of the millennium development goals has helped to reverse a decline in the share of national incomes allocated to aid. But it has yet to generate binding commitments or concrete plans. Halfway to the 2015 deadline, progress is partial, halting and insufficient to meet most goals. To accelerate progress, scaling up is needed. Capacity building should strike the right balance between hierarchical, individualistic and relational conceptions of development. Projects should be used to experiment, innovate, learn and evaluate what works and does not work. To trigger an accelerated and self-sustaining reform of the global policies that shape development, new partnerships will be needed to mobilize skills and resources; to generate new ideas; to mobilize public opinion; to trigger judicious standard setting and to implement scaled up development programs. These new development coalitions are likely to take the form of global networks combining the legitimacy of governments, the ethics of the civil society and the innovative energies of the private sector.

Creating good policies is a complex and dynamic process. A program can be evaluated, found to improve people’s lives, and be scaled up. However, in the longer run, these programs interact with other policies, contexts change, and policymakers are in constant need of new information and evidence to adjust their programs and address new challenges. This presents an opportunity for researchers and policymakers to collaborate on long-term evaluations to understand how program impacts and contexts change over time, and how policies can be adjusted according to the evolving needs of the people. Yet long-term evaluations are rare after a successful program has been expanded; Governments often decide to expand these programs to control areas that did not originally receive the program and assume that progress continues. In the case of the Generasi program (the National Community Empowerment Program—Healthy and Smart Generation), the Government of Indonesia (GoI) took a different approach. Based on the results of a 2009 evaluation of the program, as they scaled up Generasi they prioritized expansion to the least developed regions of the country first, rather than expanding it to the control areas from the original study—such as West Java, East Java, and North Sulawesi, which had better baseline access to infrastructure and health care services. This created an unprecedented opportunity for a long-term randomized evaluation of the original intervention.

In the face of climate change, we urgently need to find pathways to a low-carbon economy. Only then can we improve the well-being of nine billion people by 2030 and achieve the Sustainable Development Goals (SDGs). Over the last 10 years, SEED has awarded more than 200 enterprises in over 40 countries for developing business models which contribute to sustainable development by solving social and environmental problems on a local level. SEED represents a vast repository of solutions that can and should be replicated. This study finds answers to the following questions:
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?

Eighteen inspirational rural development success stories Covers Africa, Asia, and Latin America In the personal words of international development initiators, Reasons for Hope tells true stories of what can be done to improve the lives of those in rural communities. Read individually for specific guidance, or collectively for cumulative advice on how to promote the most desirable forms of rural development, these stories offer a timely and crucial message concerning the plight of the rural poor.

Purpose
Despite increased attention to, and investment in, scaling up of disaster risk reduction (DRR), there has been little detailed discussion of scalability. The purpose of this paper is to respond to this critical gap by proposing a definition of scaling up for DRR, what effective scaling up entails, and how to measure and plan for scalability.

Design/methodology/approach
A literature review of debates, case studies and good practices in DRR and parallel sectors (i.e. education, health and the wider development field) unveiled and enabled the weighting of key concepts that inform scalability. The mixed methods research then developed, validated and employed a scalability assessment framework to examine 20 DRR and five non-DRR initiatives for which a minimum set of evidence was accessible.

Findings
Support from national, regional and/or local authorities strongly influenced the scalability of all initiatives assessed. Currently, insufficient to support effective scaling up, monitoring and evaluation were also found to be critical to both identify potential for and measure scalability.

Originality/value
The paper ends with a scalability assessment and planning tool to measure and monitor the scalability potential of DRR initiatives, highlighting areas for corrective action that can improve the quality and effectiveness of DRR interventions.

Most practitioners, policy-makers, researchers and funding agencies would agree that there is sufficient knowledge and experience to address most social problems. The challenge is to extend, disseminate or replicate this information so that an ever-increasing number of people can benefit. The replication strategies used in the social sector can be broadly grouped under two contrasting labels: universalist and contextual. Both have their merits and they can often be combined, bringing out their individual strengths and mitigating their weaknesses. This paper reviews the key issues and methodologies involved in the replication of social programmes and explores the linkages between the parallel, but insulated, discourses on this subject. Rather than produce a list of recommendations, the paper attempts to explore the complexities underlying the processes of going-to-scale. Finally, promising trends in social programming, policy and practice are examined and the research tradition in related social science disciplines is explored to elicit pointers for replication in the social sector.

Background
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.

The international development community has rallied around the Millennium Development Goals in an unprecedented way. Microfinance supports the MDGs for the simple but powerful reason that many of the MDGs—especially those for improved nutrition, health care, and education—are the priorities of poor people themselves all over the world. Study after study confirms that poor families with access to financial services eat better, keep their children in school longer, receive better medical care, and live in safer housing than those who do not have such access, other factors being equal. Access to financial services hands poor people the tools to solve their own problems and to chart their own paths out of poverty. The problem, then, is not establishing whether microfinance works. The problem is how to increase its scale exponentially. Today microfinance is only reaching about four percent of the estimated demand for financial services by poor households. Annual rates of increase are also stuck in single digits. We cannot reach the hundreds of millions of poor people who urgently need access to finance by replicating nonprofit microfinance institutions one branch at a time. Rather, to achieve massive scale and fulfill its huge potential, microfinance must become fully integrated into developing countries’ mainstream financial systems, rather than being isolated in a niche of the development community. After all, poor people are the overwhelming majority in those countries. It is illogical, as well as unjust, that any country’s formal financial system would serve a handful of elites while excluding most of its citizens. The cases prepared for the “Scaling Up Solutions to Poverty Reduction” conference in Shanghai (May 2004) represent some of the most powerful examples of scaling up in the history of the modern microfinance industry. The cases provide notable diversity in terms of both geography and institutional type. They range from Central Asia, South Asia, Latin America, and Africa, and include traditional non-governmental organizations, commercial banks, agricultural banks, and building societies. The commonalities, however, are perhaps even more striking than the differences. All the institutions made a conscious management decision to pursue scale while serving poor clienteles. All demonstrated creativity and a willingness to take calculated risk. And all operate in accordance with commercial business principles, regardless of governance structure or legal status.

Bold actions are urgently needed if the development vision that world leaders laid out in remarkable unison at the turn of the century is to be realized. The Millennium Development Goals (MDGs) and the Monterrey Consensus have created a powerful global compact for development. The MDGs set clear targets for eradicating poverty and related human deprivations. The Monterrey Consensus stresses the mutual accountability of developing and developed countries in achieving these goals. But the continued credibility of this compact hinges on expediting its implementation. Nearly five years have passed since the Millennium Declaration was adopted, and current stocktaking of progress during that time has focused global attention on the need to scale up action—making 2005 a crucial year to build momentum for the MDGs. Without faster progress, the MDGs will be seriously jeopardized—especially in SubSaharan Africa, which is off track on all the goals. At stake are prospects not only for hundreds of millions of people to escape poverty, disease, and illiteracy, but also prospects for long-term global security and peace—objectives intimately linked to development. Behind cold statistics on the MDGs are real people, and lack of progress has immediate and tragic consequences. Every week in the developing world, 200,000 children under five die of disease and 10,000 women die giving birth. In Sub-Saharan Africa alone, 2 million people will die of AIDS this year. And as many as 115 million children in developing countries are not in school. The need to scale up and speed up action is thus urgent, and the opportunities presented by the year 2005 must be seized. To be sure, there has been progress. Developing countries have continued to improve their policies and governance, which has contributed to an encouraging acceleration in their economic growth. Even Sub-Saharan Africa may be turning the corner, with several countries in the region showing notable progress in reforming policies and reviving growth. Developed countries have increased aid and introduced actions to make it more effective. Some initial steps have also been taken toward trade policy reform. But, overall, progress has been slower than envisaged, uneven across policy areas and countries, and far short of what is needed to achieve the MDGs. With just a decade to go until 2015, achieving the MDGs seems daunting, especially in Sub-Saharan Africa. But rapid progress is possible—if there is sufficient commitment to reform and sufficient support from development partners. Better-performing developing countries provide reasons for hope for others. Even in many lagging countries, including in Sub-Saharan Africa, advances are being made GLOBAL MONITORING REPORT 2005 xvii Executive Summary and the ground is being laid for better performance. What is needed is to quicken and broaden this progress, based on the framework of the enhanced global partnership envisaged at Monterrey.

As a global nonprofit organization, VisionSpring has worked for more than 15 years to create affordable access to eyewear, everywhere. While the mission has remained central, the strategies and business models used to achieve these goals have evolved radically over time. As is the case across sectors, reaching impact at scale requires constant iteration and often involves pivots. When VisionSpring sought to scale the “Hub and Spoke” retail model across Central America, results were not as expected: After a promising start, net income was significantly lower than forecasted and impact among target customers was not scaling as planned. 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.

“Scaling-up” is the process of reaching larger numbers of a target audience in a broader geographic area by institutionalizing effective programmes. While there is no precise definition identifying the amount of increased programming or coverage required for scaling-up, scaled-up programmes usually reach (or providing access for) much of the targeted population within a specified area. Why is scaling-up important? In view of limited resources, and because the reproductive health needs of young people are so great, it is important to plan programmes that reach as many of the targeted population as possible. The reality of HIV/AIDS has made this need even more urgent. What are the approaches to scaling-up? Adequate planning is an important component of the scaling-up process. Policy support, leadership, networks, and cost all relate to the feasibility of “going to scale.” Many of these factors can be identified in advance, during both initial project planning and also during the pilot phase. It is critical that all organizations and “players” who will be counted on to move the programme to scale must be involved from the start to best support expansion efforts. For example, many activities have been designed as pilot or demonstration projects, but have not considered the requirements of translating such activities to a broad scale. Thus, even if such projects prove effective, a process is not in place to expand or scale-up. As a result, projects that are evaluated and show impact are often “boutique” projects - that is, they involve few participants at high costs and are unlikely candidates for effective scaling-up. The FOCUS on Young Adults Program identified four key approaches to scaling-up project activities. These included: Planned expansion – expanding the number of sites and the number of people served by a particular programme model once it has been pilot tested and shown to be successful. Association – expanding programme size and coverage through common efforts and alliances across a network of organizations. Grafting – adding a new initiative to an existing programme, such as adding sex education to academic school programmes or making family planning programmes originally created for adults more “youth friendly.” Explosion – implementing at a large scale at once, usually with the support of high-level policy.

From 1999–2003, FRONTIERS implemented a Global Agenda program of operations research (OR) projects to address the reproductive health (RH) needs of adolescents in four countries— Bangladesh, Kenya, Mexico, and Senegal. The project was implemented in two districts of Western Province in Kenya, and was known as the Kenya Adolescent Reproductive Health Project (KARHP)1 . The project supported a public sector, multisectoral intervention to enhance young people’s knowledge and behaviour regarding reproductive health and HIV prevention, and systematically tested its feasibility, acceptability, effectiveness and cost. This OR project, implemented jointly with PATH, demonstrated that such a multisectoral intervention could be implemented by the public sector, was acceptable to communities, its effect in influencing reproductive health and HIV/AIDS knowledge, attitudes and behaviour was understood, and the type and amount of financial and other resources needed to implement each of the component activities was calculated. The pilot project showed that it was possible to reach 50% of the adult population (over 7,200) and over two-thirds of all 10-19 year olds, in and out of school (over 30,000) living in the project area, through supporting three Government of Kenya ministries: Ministry of Education, Science and Technology (MOEST); Ministry of Gender, Sports, Culture and Social Services (MGSCSS); and Ministry of Health (MOH). FRONTIERS and PATH subsequently undertook a broad and systematic dissemination of the findings and their programmatic, financial and policy implications. Dissemination included the communities where the study was implemented, district level ministry staff, and national-level stakeholders in the three ministries and other interested organizations. These activities were completed by April 2003. Underlying the strategy of working directly with the existing structures and staff of the three ministries was the expectation that this approach would facilitate incorporation of effective reproductive health (RH) and HIV prevention components into each ministry’s routine operating procedures, with minimal disruption or additional resource requirements. Through their continual engagement in the project at the community, location, district, provincial and national levels, the three ministries have shown their commitment to the institutionalization of these activities so that they can be sustained within their routine work plans and budgets. Given the success of the KARHP pilot activities, and the initial expressions of interest by the communities and all three ministries in incorporating them into their routine operations, a followon project was initiated for the period August 2003 to April 2005 with support from USAID/Kenya. This project sought to facilitate the process of “adapting and institutionalizing” the reproductive health and HIV activities within the three ministries at the district level initially, and to create conditions for their replication in other districts

Few development projects have addressed the sexual and reproductive health (SRH) needs of university students in West Africa or sought to promote student leadership to extend SRH benefits to others. This report presents results from the Evidence-toAction Project‘s University Leadership for Change Initiative in Niger which had the goal to begin filling this gap. The Initiative used an innovative behavior change methodology with students at Abdou Moumouni University in Niamey, Niger and subsequently expanded it to three additional universities by applying ExpandNet scale-up approaches. 200 students trained as peer leaders reached almost 8,000 youths with SRH information and counseling, student leaders and university clinic staff distributed nearly 80,000 condoms and the project achieved national policy change through its collaboration with the Ministry of Public Health and the Ministry of Higher Education, Research and Innovations. The report concludes with key lessons about the benefits of student engagement and creativity in this effort. (Afr J Reprod Health 2019; 23[1]: 55-64).

Keywords: University student leadership, sexual and reproductive health, Niger, scaling up

The international development community’s desire to alleviate poverty and improve health outcomes presents an extraordinary opportunity to transform the lives of young people, particularly girls. Cycles of illiteracy, poor job prospects, and social isolation can be broken, but will require concerted efforts to reach large numbers of vulnerable adolescent girls with robust asset-building programs. Scaling-up effective pilot programs will be critical to achieving these goals. While there is an expanding body of research around scaling-up health interventions, less is known or documented about scaling-up cross-sectoral programs for adolescent girls. Bringing to scale programs directed toward poor, often invisible and voiceless girls, poses unique challenges. Given that this is a relatively new field at an early stage of experimentation, the evidence base regarding which strategies are most effective is still emerging. The Population Council has been exploring a variety of approaches to meet these challenges in diverse settings and gathering evidence to inform program and policy development. Scaling-up as institutionalization process Key observations around scaling-up adolescent girls programs Transfer of the innovation from originator to adopter; roles of NGO and government Challenges of scaling-up programs for vulnerable girls Maintaining quality and fidelity while containing costs Conditions that enhance the likelihood of successful scale-up Kishori Abhijan, Bangladesh—“Adolescent Girls’ Adventure” More than just numbers! Scaling-up programs for adolescent girls is a strategic process of institutionalization and the solidification of rights into various structures.

Adolescent sexual and reproductive health gained particular traction in Mozambique following the 1994 International Conference on Population and Development leading to the inception of Programa Geração Biz (PGB), a multi-sectoral initiative that was piloted starting in 1999 and fully scaled-up to all provinces by 2007. We conducted a systematic review of the literature to gather information on PGB and analyzed how it planned and managed the scale-up effort using the WHO-ExpandNet framework. PGB’s activities comprised a clear and credible innovation. Appropriate resource and user organizations further facilitated national scale-up. Challenges relating to the complex nature of the multi-sectoral approach and resistance due to norms about adolescent sexual and reproductive health hindered scaling-up in some geographic areas. The national government exhibited commitment and ownership to PGB through budgetary support and integration into multiple policies. This study adds to the documentation of successful scaling-up strategies that can provide guidance for policy makers and programme managers.

Background
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.

Since 2006, Udaan—a school-based adolescent education program in Jharkhand, India—was the only at-scale state-run program in the country. To determine factors that contributed to Udaan's scale-up and longevity, this study drew information from programmatic reports and interviews with the Centre for Catalyzing Change staff. Key factors for Udaan's success included an enabling policy environment, a willing government that supported and operationalized the program, a knowledgeable and committed NGO partner, sustained funding, and a commitment to constant improvement through evaluation. Udaan provides an example of a well-designed, implemented, and evaluated school-based adolescent health program that has been operating at scale over a sustained period. Other programs in India and elsewhere can benefit from learning from Udaan's experience.

KEYWORDS: Social determinants of health adolescent health sexuality education

Background
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.

This case study illustrates the key factors contributing to workforce systems change over a decade-long period in Rwanda (roughly 2008–2019). Rather than attempting to present an exhaustive picture of the Rwandan workforce system, we offer a snapshot of what we have learned about the system and how it has changed. Although we do so from the vantage point of an international implementing organization, we hope this case study informs a range of system stakeholders—including governments, donors, and international organizations— about how they can work together to improve youth skills development and employment outcomes.

Community involvement is considered an important element of most health and development programs. Local knowledge can inform program design when community members are involved from the beginning, and community action extends the reach and scope of interventions. Experience with programs in many sectors has shown that behavior change to improve people’s health and well being requires changes in knowledge and attitudes not only at the individual level, but also at the community level. Community-level shifts in attitudes and social norms create a more supportive environment that enables individual to adopt and maintain new behaviors. Community involvement can also create the sense of ownership necessary to sustain behavior change beyond the life of an externally funded program. Involving both youth and adults in communities is particularly important for youth reproductive health (YRH) and HIV programs. Some degree of youth involvement is essential for such programs to function. Greater levels of youth participation may also increase the impact of reproductive health and HIV prevention interventions. Programs for youth that are designed only by adults tend to be based on an idealized view of how young people should behave. Young people’s participation in planning, implementation and evaluation is expected to ground programs in the real needs of youth and the support systems they actually use, making interventions more relevant to their intended beneficiaries. Beyond youth participation, the involvement of the larger community is also considered critical to the success of youth HIV and reproductive health programs. Such programs cannot work with young people in isolation. In fact, in most societies it would be impossible to reach young people without at least the cooperation of the adults responsible for their physical and social development. Moreover, because young people and adults in a community often have different perspectives, involving only young people and not adults in YRH/HIV programs can be controversial. Conversely, adult involvement in such programs can enable adults to provide more effective support for youth, improve communication between adults and young people, and increase community ownership and sustainability of YRH efforts. Although the need for community involvement in youth programs seems clear, only a handful of studies have actually attempted to measure the added value of incorporating such participation into an YRH program. Program experience in community involvement for youth reproductive health and HIV prevention – though extensive – is poorly documented. Thus, to understand the value of community involvement in youth reproductive health and HIV programs requires more research. Questions remain about the most effective ways to encourage, support, and sustain community members’ participation in such programs.

Purpose
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

Background:
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.

What is “scaling-up”? Scaling-up community mobilization means expanding the impact of a successful mobilization effort beyond a single or limited number of communities to the regional, national, or even multinational level. While the appeal of scaling-up is obvious, the challenge is to do so without diminishing the quality of the original effort. Experience over the last decade is beginning to show that community mobilization approaches can be scaled up. This chapter will look at some of these experiences and will lay out steps to help you scale up successful community mobilization approaches. Programs achieve scale either by starting out at scale (or very quickly going to scale) or through incremental efforts to expand coverage.1 Programs typically scale up in one of five major ways: Planned Expansion: a steady process of expanding the number of sites for a particular program model once it has been pilot-tested and refined. 2 Explosion: sudden implementation of a large-scale program or intervention, without any cultivation of policy support or gradual organizational development prior to implementation. Association: expanding program size and coverage through common efforts and alliances among a network of organizations. Grafting: adding a new young adult reproductive health program, for example, to an already existing program. Diffusion: other organizations learning about approaches through access to materials and case studies and replicating the approach. Without significant uptake—the degree to which other significant development actors (e.g., NGOs, community-based groups, bilateral and multilateral agencies, host governments) adopt and adapt methodologies— scale cannot be reached. Uptake is significantly different from replication in that the former involves adaptation of strategies or methodologies to fit varying program contexts. In order to achieve substantial uptake, an organization needs to: • Engage in experience-based advocacy. • Garner recognition and attention for its work. • Embrace monitoring and evaluation practices that produce credible results. • Engage in effective networking and strategic partnering.3 Why scale up? Scaling-up successful community mobilization approaches offers a number of benefits. Among other things, it can: • Extend the positive benefits of your program to more people who need and want them. • Maximize resources and the investment made in developing the approach. • Contribute to a growing awareness of the particular health and related issues that are of concern to the mobilization effort and help to foster changes in social norms. • Increase support for changes in policies and resource allocation related to the issue as more communities begin to address their needs. • Begin to address some of the underlying causes of health problems as a critical mass of people develop their knowledge and skills and build organizational linkages within and beyond individual communities.

As in many developing countries, young people in Kenya and Senegal—those between ages 10 and 20—account for about 25 percent of the population. To ensure their future contribution to their countries, it is thus of vital strategic importance to safeguard the welfare of these young people. Rapid social change in both countries exposes youth to sexual and reproductive health risks, including unintended pregnancy, sexually transmitted infections (STIs) including HIV, and sexual violence. In Kenya, the greatest risks are from unplanned pregnancy and STIs, including HIV. In Senegal, family members and the health care system often are ill-equipped to provide youth with information on reproductive and sexual health or to advise them on how to sexual risks (Askew, Chege, Njue, and Radeny 2004; Diop et al. 2004). Beginning in 1999, the Population Council’s Frontiers in Reproductive Health Program (FRONTIERS) conducted operations research (OR) studies that tested the feasibility, acceptability, and cost of a public-sector, multisectoral intervention to enhance young people’s reproductive health knowledge and behavior. Study findings showed improvement in young people\'s reproductive health behavior and knowledge, successful engagement of government ministries, and increased understanding of the reproductive health needs among communities. Communities and the participating ministries in both Kenya and Senegal expressed interest in incorporating elements from these interventions into their routine operations. FRONTIERS and its local partners launched follow-on projects in both countries to adapt, expand, institutionalize, and scale up the activities. This Program Brief describes the processes involved in institutionalizing and scaling up the multisectoral interventions. n Protecting youth reproductive health is an important strategy for developing countries. n Multisectoral approaches that engage government agencies, communities, and youth are vital for sustainable change. n It is critical for implementing agencies to institutionalize, budget for, and monitor interventions within their routine job responsibilities.

Background
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.

Background:
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.

Purpose
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

Background
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.

Playful Learning Landscapes seeks to transform everyday spaces into playful learning opportunities to maximize “the other 80 percent” of time that children spend outside school. It lies at the intersection of the growing Child Friendly City movement and a global development agenda that calls for access to high-quality early childhood education for all. A joint project of Temple University’s Infant and Child Laboratory and the Brookings Institution, Playful Learning Landscapes is a broad umbrella initiative that marries community involvement and learning sciences with placemaking in order to design carefully curated playful experiences in everyday spaces. As it focuses on learning outcomes, particularly for children and families from under-resourced communities, Playful Learning Landscapes offers a new way to involve families in the kinds of experiences that enrich relationships and enhance children’s development.

Practicing implementation, development, outcomes, evidence

Using the science and practice of implementation to strengthen equity in our education systems, support our educators, and improve outcomes for children, families, and communities. To support implementation of instructional and leadership practices that lead to improved outcomes for students with disabilities, the SISEP center will… Increase Capacity of selected State Education Agencies (SEAs), Education Service Agencies (ESAs), Local Education Agencies (LEAs), and Charter Management Organizations (CMOs) Increase Capacity of OSEP-funded TA centers systemic change efforts Increase knowledge, skills, and competencies of LEA superintendents and other leaders Increase body of knowledge on developing an infrastructure

What can a Dutch supplementary school program teach us about successful scaling? As I will argue in this post, quite a lot, particularly for those of us who work on international education projects. But before I embark on this, let’s go to Molenbeek, Belgium.

If ‘necessity is the mother of invention’, the education crisis in many developing countries calls for some fresh thinking about how to provide quality education for all children. It is debatable how radical education reform needs to be and there is plenty of opportunity to follow John Hattie’s advice to build on existing best practice and “stop ignoring what we know and scale up success”1 . But, there is also opportunity to be more disruptive, to reinvent schools and transform learning, with abundant examples from around the world of how change in education can be managed and children can learn in different ways. This paper offers insights into the current theory and practice of innovation for education. Drawing on Cambridge Education’s programme experience across many cultures and contexts, it identifies the conditions that have led to successful outcomes when introducing or supporting innovative approaches for education. Rationalising innovation for education – finding the middle ground Cambridge Education identifies six stages of innovation from the generation of new solutions to defined problems, through their development and testing, then scaleup and wider adoption. Leadbeater and Wong’s framework for innovation shows a continuum of innovation from improvements in current ways of working in schools, to the possibilities of reinventing schools, engaging the wider community to supplement what schools can offer, and possibly transforming learning beyond schools altogether. However, opinions are divided. Some practitioners seek more disruptive innovation in education and propose radical change to stagnating and redundant education models and systems. Others see innovation as, at best, a sham and window dressing of steady progress and, at worst, damagingly destructive and needless change at the expense of the tried and tested. Nonetheless, there is perhaps a middle ground. Even the most radical reformers recognise the merits of effective schools supported by wider society and understand that much innovation will be incremental and in familiar surroundings. Most practitioners would agree that while global education systems continue to fail millions of children, it is important to consider the possibility of adopting new approaches, even going beyond conventional school systems, and to be prepared to manage the risks of change.

Slow progress towards MDGs has rekindled interest in social transfers as a means to reduce poverty and accelerate progress towards the Millennium Development Goals (MDGs). For example, the Commission for Africa has called for a major scaling up in social assistance to vulnerable children1 . Social transfers are increasingly recognised as an important component of an overcall care package for children affected by AIDS. The World Bank is scaling up its support to social transfers as a key policy response to inequities in health and education opportunities for the poorest and socially excluded groups2 . UNESCO promotes targeted social transfers as a way of changing the balance of incentives for girls to attend school3 . WHO has recently launched a Commission on Social Determinants of Health, which includes a review of the potential of social transfer programmes to improving health. This paper provides background analysis to support a DFID Policy Division Briefing Note on Using Social Transfers to Improve Human Development4 produced by the Scaling up Services team in collaboration with the Social Protection team, part of a series of briefing notes on social protection. This work complements DFID’s Practice Paper Social Transfers and Chronic Poverty (2005)5 . It also forms one part of DFID’s Scaling up Services team’s workstream on promoting equitable access to health and education services. Policies that promote poor people’s access to health and education services are critical to making best use of scaled up resources. Scaling up poor people’s access will require a combination of health and education system investments along with investments outside those sectors. These may include demand side approaches that promote the use of available services, as well as increasing service coverage. This paper focuses on the impact of one form of demand-side policy option – social transfers, particularly cash transfers and vouchers - on access to health and education services by the extreme poor. It also touches upon the broader contribution that social transfers make to human development outcomes. Section 2 describes social transfers and their relevance to scaling up health and education services and outcomes for the extreme poor. Sections 3 and 4 summarise the evidence on the effectiveness and cost-effectiveness of social transfers in relation to health and education access and outcomes. Sections 5 and 6 outline a range of factors, including service provision context, that need to be considered when assessing policy options in different contexts. Section 7 sets out some of the country ownership and aid instrument issues, whilst Section 8 looks at the opportunities that scaled up resources has for social transfers in the pursuit of equitable human development goals. Section 9 concludes by identifying the gaps we still need to fill in the evidence base.

In Senegal, school-based sexuality education has evolved over 20 years from family life education (FLE) pilot projects into cross-curricular subjects located within the national curriculum of primary and secondary schools. We conducted a literature review and semi-structured interviews to gather information regarding the scale and nature of FLE scale-up. Data were analysed using the ExpandNet/WHO framework, conceptualising scale-up from a systems perspective as composed of interrelated elements and strategic choices. Key enabling factors that facilitated the scale-up of FLE included (1) programme clarity, relevance and credibility; (2) programme adaptability to young people’s evolving sexual and reproductive health priorities; (3) the engagement of a strong and credible resource team comprising government and civil society agencies; (4) a favourable policy environment; and (5) deliberate strategic choices for horizontal and vertical scale-up. Barriers included sociocultural conservatism that creates resistance to content areas deemed to be culturally sensitive, resulting in partial scale-up in terms of content and coverage, as well as structural barriers that make it difficult to find space in the curriculum to deliver the full programme. Lessons learned from Senegal’s experience can strengthen efforts to scale-up school-based sexuality education programmes in other culturally conservative low- and middle-income countries. Senegal young people comprehensive sexuality education school sex education scale-up

The issue of “scale” is a key challenge for school reform, yet it remains undertheorized in the literature. Definitions of scale have traditionally restricted its scope, focusing on the expanding number of schools reached by a reform. Such definitions mask the complex challenges of reaching out broadly while simultaneously cultivating the depth of change necessary to support and sustain consequential change. This article draws on a review of theoretical and empirical literature on scale, relevant research on reform implementation, and original research to synthesize and articulate a more multidimensional conceptualization. I develop a conception of scale that has four interrelated dimensions: depth, sustainability, spread, and shift in reform ownership. I then suggest implications of this conceptualization for reform strategy and research design.

Through accompanying the scaling journey of PEC, lessons emerged from the case centered around four key themes that were consequential to PEC’s scaling success to date, and which will continue to play a critical role in future efforts. These themes are: 1) institutionalization as a pathway to sustainable scale; 2) partnerships and champions; 3) costs and financing; and 4) adaptation and continuous learning. Each of these themes offers lessons from the case of PEC and targeted recommendations not only to support ongoing progress to expand and deepen the impact of PEC but also to inform scaling efforts of other evidence-based education initiatives. Below is a brief overview of each of the lessons with targeted recommendations for implementers, policymakers, funders, and researchers further detailed in the full report

Key considerations for scaling up the use of early literacy learning practices with infants, toddlers, and preschoolers with developmental disabilities and delays by early childhood intervention programs and practitioners are described. Th e paper includes a defi nition of scaling-up, a description of the levels and attributes of the proposed scaling-up approach, and the particular elements of scaling-up that will be used to promote the adoption and sustained use of evidence-based early literacy learning practices.

Ideas and action which lead to change and development at the grassroots need to be pushed ahead, very swiftly, after the initial period of learning. In this spirit, Grassroots has been actively involved in scaling-up grassroots development across the villages in the central and western Himalaya in India. The idea of writing some thoughts on this matter in the ELP newsletter, provides Grassroots with the opportunity of sharing experiences and learning from the feedback of ELPers How to scale-up the successful pilot project to benefit much larger numbers of people, over diverse conditions and ecosystems? In private sector terms, how to convert the successful “startup” into a thriving business with growing market share? The Millennium Development Goals (MDGs) establish the target numbers and timeframe that are meant to induce signatory governments to scale-up antipoverty measures quickly and effectively. The diverse experiences shared in this newsletter point to core components for successful scaling up, perhaps foremost among them, strong organizational capacity built on local trust and backed by quality training.

Many educational interventions boost outcomes for girls in settings where girls face education discrimination, but which of those interventions are proven to function effectively at large scale? In contrast to earlier reviews, this review focuses on large-scale programs and policies—those that reach at least 10,000 students—and on final school outcomes such as completion and student learning rather than intermediate school outcomes such as enrollment and attendance. Programs and policies that have boosted access and/or learning at scale across multiple countries include school fee elimination, school meals, making schools more accessible, and improving the quality of pedagogy. Other interventions, such as providing better sanitation facilities or safe spaces for girls, show promising results but either have limited evidence across settings or focus on post-educational outcomes (such as income earning) in their evaluations. We discuss three aspects of considering evidence-based solutions to local problems—constraints to girls’ education, potential solutions, and program costs---as well as lessons for scaling programs effectively. If education systems seek to expand and improve girls’ education at scale, there are tested tools that have performed effectively in multiple settings, even as education leaders, partners, and researchers collaborate to continue innovating and testing new programs at scale.

This report documents the culmination of ten years of development of a new approach to improving human service systems, organizations, and outcomes. Based on the Active Implementation Frameworks, intensive support is provided to develop implementation and scaling infrastructures in state education systems to initiate and mange change processes, and to provide reliable supports for improved teacher instruction and student learning. Measures of capacity inform action planning and monitor progress in states, regions, districts, schools, and classrooms. Implementation is a significant addition to efforts to improve education in the United States.

What does it take to transform a large, bureaucratic institution with a fractured culture and a compliance orientation into a nurturing, collaborative, vision-directed organization? This report and the accompanying research brief endeavor to answer that question by examining a humanistic and systems thinking approach to cultural change that took place over a period of two years in a large-scale, state organization. More often than not, institutions that want to change start by cultivating employees’ understanding of the need for change. They implement strategies that focus on increasing efficiency and satisfaction through structures and policies rather than spending time at the human, individual level of the system. The underlying principal of that traditional approach treats employees as cogs that can either muck up the works in opposition to change or ease the turning of the wheel by complying. In other words, the focus is most often on employee as object, rather than employee as human. In 2017, the California Department of Education’s Expanded Learning Division (after-school and summer programs) took a radically different approach by cultivating the shared humanity of those in their system. They followed a theory of change that recognized that educational improvement is a human endeavor and focused efforts on the growth and development of the adults responsible for the growth and development of children. By taking time for meditation, personal reflection, and relationship building, they acknowledged that human growth and development take time and support. Their success was guided by their clear, consistent, and compelling goal: more children experiencing high-quality afterschool programs.

This collection summarises reflections from a group of Department for International Development (DFID) education advisers, spanning a number of different contexts and aspects of the topic of education projects that are working at scale to improve learning outcomes. In the first contribution, Gibbs shares a case study of an approach used to track the scale-up of a teacher intrinsic motivation intervention in Delhi, which also supported the implementers to test, learn and adapt as they scaled. Then, Attfield provides a comparative case study of two different education contexts (Nepal and Rwanda) and considers the lessons we can learn for scaling inclusive education. Following that, Bronwin's case study of the General Education Quality and Improvement for Equity (GEQIP-E) programme draws out some useful lessons about culture change and enabling system transformation in Ethiopia, and then Atkinson and Potter discuss the in-roads being made to a better understanding of how to provide effective Early-Childhood Development (ECD) interventions at scale. Finally, Gibbs, Jones, and Hinton draw together the lessons apparent across all of these contributions, focussing on possible success factors for systems change at scale. Contents include: (1) Tackling the Scale of the Learning Crisis with Education Interventions That Work at Scale (Laura Savage); (2) Measuring Messiness: A Case Study of STIR Education's Approach to Learning in 'Real Time' While Scaling (Emma Gibbs); (3) Scaling Disability Inclusive Education in Nepal and Rwanda: Approaches, Governance Structures, and Cultures (Ian Attfield); (4) Culture for Change at Scale in Ethiopia: Resources and Challenges (Rona Bronwin); (5) Scaling Early Childhood Development Approaches: Learning from Other Sectors and Systems Thinking (Jess Atkinson and Amy Potter); and (6) Pathways to Scale: The Challenge of Creating an Enabling System (Emma Gibbs, Charlotte Jones, and Rachel Hinton).

Effective programmes introduced by NGOs in developing countries have the potential to benefit a large number of people if they are scaled up, but instances of successful scaling-up are relatively rare. This paper uses a case study of an Indian educational NGO that has scaled up rapidly and effectively in order to explore the reasons for choice of scaling-up strategy, the particular barriers to scaling-up in the education sector, and how these barriers can be overcome. It finds that, while a high-functioning NGO can successfully overcome many of the internal organisational challenges posed by scaling-up, external barriers such as the difficulty of building relationships with key stakeholders like government officials and school teachers pose significant challenges. While these difficulties could in principle be mitigated by moving from an expansion-based to collaboration-based model of scaling-up, low accountability and governance of the NGO sector make it difficult to detect the quality of potential partners. The case also shows that India’s recent law mandating CSR has increased funding availability for scaling-up, but its requirement for corporate donors to preferentially support local projects has also created some challenges by constraining NGO ability to harness economies of scale during scaling.

This report focuses on one of the scaling labs launched in Tanzania in 2018 in collaboration with the Campaign for Female Education (CAMFED). It examines the process of implementing, adapting, and scaling the Learner Guide Program, which delivers life skills and mentorship provided by local female secondary school graduates (Learner Guides) to secondary school students as part of an 18-month volunteer program, in collaboration with the Ministry of Education, Science, and Technology (MoEST) and the President’s Office, Regional Administration and Local Government (PO-RALG).

Nigeria is one of few countries that reports having translated national policies on school-based comprehensive sexuality education (CSE) into near-nationwide implementation. We analysed data using the World Health Organization-ExpandNet framework, which provides a systematic structure for planning and managing the scaling up of health innovations. We examined how Nigeria\'s nationwide programme was designed and executed. Since 2002, Nigeria has developed a well thought through strategy to scale up CSE. Crucial attributes that facilitated the scaling up included technical consensus about the innovation and clarity about its components, dissection of a complex intervention into manageable components for implementation by organisations with complementary expertise, strong political leadership and championship in concert with advocacy and technical support from non-governmental organisations, proactive and energetic involvement of community stakeholders, effective programme management, and improvements to the information management system to ensure on-track implementation and mid-course corrections to keep stakeholders, including funders, informed and engaged. Challenges included programmatic values, competing priorities for available human resources and a lack of predictable funding for sustaining a rapid scale-up effort. Despite some weaknesses, implementation has largely proceeded according to plan. The lessons learned from Nigeria\'s experience can and should be used in other settings to achieve wide-scale coverage. Nigeria adolescents comprehensive sexuality education school sex education scale up

Young people make up for 24.5 % of Latin America’s population. Inadequate supply of specific and timely sexual and reproductive health (SRH) services and sexuality education for young people increases their risk of sexual and reproductive ill health. Colombia is one of the few countries in Latin America that has implemented and scaled up specific and differentiated health and SRH services-termed as its Youth Friendly Health Services (YFHS) Model.

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.

A programme to improve school governance in MP was scaled up despite being ineffective. What can its perceived success teach us about improving public service delivery at scale? Tags: Government schools, research, teachers

Nonprofits involved in areas that address basic needs like education or health often expect that if a project or intervention is successful, government will ultimately adopt and manage it for the longer haul. For a project to reach its potential scale and sustain impact over time, many view this as the most realistic end game. Conventional wisdom holds that governments want fully formed, tested versions of programs or interventions so that it can easily scale them up.

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.

Public schools are under increased pressure to implement evidence-based substance abuse prevention programs. A number of model programs have been identified, but little research has examined the effectiveness of these programs when "brought to scale" or implemented district-wide. The current paper summarizes the application of the Adelman and Taylor's (1997) model for district-wide program implementation to the dissemination of an evidence-based parent-child drug education program called Keep A Clear Mind (KACM; Werch & Young, 1990). In addition to documenting the partnership process used to scale-up the program to a district-level, evaluation results are presented from 2,677 fifth graders in 43 schools who participated in the KACM program. Pre-post comparisons from two consecutive cohorts of students indicated a significant reduction in students' attitudes supporting alcohol use and a significant increase in parent/child communication about prevention, students' perceived ability to resist peer pressure, and their belief that it is "wrong" to use alcohol, tobacco, and marijuana. Focus groups conducted with a subset of the KACM teachers indicated great support for the KACM program, the partnership approach, and the dissemination model. Findings provide support for Adelman and Taylor's (1997) model as a framework for collaborative district-wide implementation of substance-abuse prevention programs.

In this blog series, we highlight emerging results from the GPE Knowledge and Innovation Exchange that demonstrate how demand-driven evidence can be generated and mobilized to support education systems strengthening in the Global South. This blog has been produced using notes taken during a KIX-hosted workshop at the Comparative and International Education Society Conference in April 2022, and short reflection pieces prepared by eight KIX applied research projects - explore them all here.

This critical volume combines theoretical and empirical work across disciplines to explore what threatens scalability—and what enables it—in the early childhood field. Authors and editors provide specific recommendations to help professionals refine and apply the science of scaling in their programs, research, and decision making. Written by leading experts in early childhood, economics, psychology, public health, philanthropy, and more, chapters and commentaries shine light on how to effectively use experimental insights for policy purposes. The result is a comprehensive and forward-thinking guide to the challenges and possibilities of effective scaling in early childhood and beyond. Essential reading for researchers, practitioners, funders, and policy makers alike, this book raises vital questions and provides a vision for the long-term journey to scalable evidence.

Around the world, countries are grappling with how to scale quality education for their children and youth. Quality education is at the center of a nation’s progress, and it is also enshrined in the United Nations Sustainable Development Goals, which 193 countries have recently committed to support. While the spread of schooling over the past 150 years is one of the most widely successful “going to scale” stories, this expansion too often has been met with little mastery of core academic content and higher-order thinking skills. Millions Learning: Scaling up quality education in developing countries tells the story of where and how quality education has scaled in low- and middle-income countries. The story emerges from wide-ranging research on scaling and learning, including 14 in-depth case studies from around the globe. Ultimately, Millions Learning finds that from the slums of New Delhi to the rainforest in Brazil, transformational change in children’s learning is happening at large scale in many places around the world. We find that successful scaling of quality learning often occurs when new approaches and ideas are allowed to develop and grow on the margins and then spread to reach many more children and youth. In Millions Learning, we identify 14 core ingredients, in different combinations depending on the context, that contribute to scaling quality learning. Each of these ingredients is central for scaling effective approaches that improve learning. Their importance is frequently reinforced from evidence in the broader scaling literature. They include essential elements for designing, delivering, financing, and enabling the scaling of quality education.

Theory:
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.

Already more than a full year into the COVID-19 pandemic, it is sobering to reflect on the ongoing responses to the global pandemic, as well as future disruptions to children’s learning. The past year has really put to the test scaling principles and elucidated important lessons about catalyzing and sustaining transformative change in rapidly evolving contexts. Many of these principles—such as adaptive learning and systems thinking—are being unpacked and explored in Real-time Scaling Labs (RTSL), a collaboration with the Center for Universal Education at Brookings and local institutions and governments around the world to learn from, document, and support education initiatives in the process of scaling. In Botswana, Young 1ove and CUE have been partnering on an RTSL convened by the Ministry of Basic Education (MoBE) focused on scaling Teaching at the Right Level (TaRL). The experience of the Botswana scaling lab over the past year offers several important insights and reflections that may be useful more broadly for those working to affect large-scale improvements in children’s learning, particularly in low-resource environments.

For most young Africans, secondary education is the last schooling they will receive before entering the workforce. High quality, relevant secondary education that is accessible to all, can prepare youth to enter the workforce, improve productivity, and spur economic transformation, unlocking a virtuous cycle of both human and economic development.

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.

One is the famed Hawthorne effect (named not for the person who coined it—Henry Landsberger—but for the name of the company he was studying: Hawthorne Electric Company). This is the tendency for people who know they are being observed to act better (like how employees work harder when they know the boss is watching). Participants who know they’re in an innovation pilot tend to perform better than they otherwise would. This can produce overstated data. Another bias is the Rosenthal effect (sometimes known as the Pygmalion effect). The Rosenthal effect—named after psychologist Robert Rosenthal—is that people will live up or down to the expectations that others hold for them. An example is when students perform better if their teacher has high expectations for them and perform worse when the teacher’s expectations are low. Participants in pilot studies often know that the people piloting the innovation have high expectations for them and so, consciously or not, they will perform at a higher level. Again, this can lead to results that don’t necessarily translate for the same innovation at scale, where expectations may get diluted or wane. Aside from these two effects, there are other methodological concerns bringing an innovation from pilot to scale. Though they’ve been described by many researchers over the years, one helpful framework comes from Abhijit Banerjee and his colleagues who discuss six potential errors. One is market equilibrium: Per-unit costs of things change when an innovation is scaled; this alters the benefit/cost ratio. A second one they term positive spillover effects: their version of the Hawthorne effect. A third is political patronage: As an innovation expands, so do opportunities for corruption and collusion. The fourth is context dependence: There may be something unique about the context in which the pilot occurred that’s not true for the scaling context. The fifth is self-selection bias: Schools and local governments choosing to participate in pilot efforts are likely atypical—they’re reformers or people willing to work extra hard. And the sixth is pilot bias: The logistics and funding needs of a pilot are often easier to manage than administering the innovation at a larger scale.

Provision of quality, inclusive, and equitable education remains one of the biggest challenges for low- and middle-income countries (LMICs). Two hundred and sixty million children are currently out of school, and as many as 8 out of 10 children in low-income countries are functionally illiterate by their 10th birthday. COVID-19 has intensified this, with early data suggesting the pandemic may have wiped out 20 years of education gains. Despite the efforts of global, national, and local actors, education improvement is moving too slowly and unevenly to address the magnitude of the need.

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.

Education is crucial for the cultivation of successful individuals, healthy communities, robust societies, strong economies, and a healing planet. Yet, while most available education measures show impressive improvement in access in low- and middle-income countries over recent decades, there remains a heartbreaking gap in educational outcomes between and within countries. This is partly because, while access to school has increased, the quality of learning still often languishes—and that was before the COVID-19 pandemic.

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.

Interest in scaling promising innovations to effect systemic change in education around the world has grown over the last decade. Scaling has become fashionable because the modern landscape of educational improvement is littered with short-term projects that temporarily succeeded only to later dissipate, isolated pursuits that never crossed into broad adoption, or specialized policy programs that floundered. Moving beyond 20th-century technical-rational implementation and acknowledging the mixed history of global development in low-and middle-income countries, newer iterations of scaling have sought to collaboratively embed promising education ideas and technologies into whole systems. Increased recognition of the interconnectedness of culture, governments, global development architecture, and the learning sciences has reframed education scaling as a holistic process of mutual adaptation and collective transformation. Lasting impact has replaced size or scope as the goal. As a result, this past decade of scaling and research has offered hope and possibility—even as it has also underscored the sometimes maddening complexity of this work.

It’s well known that children in low- and middle-income countries are not learning enough, with half of children unable to read and understand a simple text by age 10. So, what can we do to change things? There’s a growing body of evidence about approaches that have successfully improved learning (see here for example) but these are rarely taken to scale or have more limited impacts when they are replicated or scaled. With a bleak picture on learning outcomes globally and the clock ticking on SDG4, it’s hard to know what can be done to move the needle and to get more children acquiring basic skills—in large numbers—across the world.

A few key themes emerge from the above scaling resources, the first being the importance of planning for scale from the outset. That is to say, if scaling is the goal, it must be baked into plans from the start, which may include building up organizational capacity, securing sustainable funding, and planning for potential challenges. This idea is reinforced in the Millions Learning study as well, which finds that planning from the outset requires a clear vision of what the endgame is and a theory of change about the best way to get there in order to successfully achieve scale. However, simply designing for scale does not guarantee large-scale impact. Implementation at large scale can be messy and complex and may require new expertise and capacity. For example, those who were involved in the initial design of the innovation may not always be the best-equipped to take the innovation to scale. Thus, it is vital that an organization remains flexible in order to prepare itself for the shifting demands of the scaling process. Furthermore, scaling can take on many different forms and look different in various contexts. Regardless of the path to scale, it is clear that scaling does not follow a linear path but is an iterative learning process. While a first attempt to scale may fail, it is important to learn from the process and have space to iterate and evaluate once again. Therefore, it is vital to continuously monitor and evaluate efforts to scale to learn from mistakes and adjust to rapidly changing environments. This echoes our own recommendations in the Millions Learning report, which encourages a stronger culture of research and development in global education.

There is no rigid recipe for scaling quality learning, but successful efforts require attention to design and delivery, stable access to finance, and an enabling policy environment. We are one year closer to the 2030 deadline for the United Nations' Sustainable Development Goals, and when it comes to education, it does not appear that we are on track. If current trends continue, by 2030, nearly one billion school-aged children will not have basic secondary skills needed to succeed in life and work. Of this population, the vast majority will live in low- and middle-income countries, where the International Commission on Financing Global Education Opportunity estimates that only four in 10 children of school age will have the minimum secondary-school-level skills needed for a successful future. The good news is that we know that large-scale progress, in both getting children into school and learning, is possible—and possible for some of the most marginalized communities. In a report released last year by the Center for Universal Education, titled Millions Learning, we found successes in scaling improvements in children’s learning in many places around the world. Drawing from current literature and an in-depth review of case studies, we have identified a “secret sauce to scaling quality education.” While certainly no rigid recipe for scaling exists, we have found 14 core ingredients that appear to contribute to scaling quality learning, with the right combination depending on the context. We’ve grouped these ingredients into four areas:

According to data released in 2018, only 12 percent of children tested in 7 low- or middle-income countries met minimum proficiency for math, and 23 percent for reading. This compares to 77 percent and 80 percent, respectively, in wealthier OECD countries. To discuss how the global education system can bring about transformational change, Jenny Perlman Robinson, a senior fellow with the Center for Universal Education at Brookings, joins the show to talk about her research on scaling—or expanding and deepening the impact—of education programs around the world. She also shares her discussions with three education leaders she interviewed at a global meeting in Switzerland this summer. These experienced leaders possess deep insights on the role that public, private, and civil society actors can play in scaling and sustaining education programs, and they bring fresh perspectives on the topic from around the globe. Also on this episode, Senior Fellow Molly Reynolds breaks down what’s happening in Congress as it returns to work after a summer recess.

Given the magnitude of education challenges around the world, it is increasingly clear that large-scale, systemic change is urgently needed. In “normal” times, 258 million children and youth around the world are out of school[1] and 617 million are in school but not learning the basics.[2] As a result, 53 percent of children in low- and middle-income countries cannot read or understand a simple story by the end of primary school.[3] Moreover, significant inequities persist between and within countries, with the poorest and most marginalized the most likely to be left behind or excluded. The COVID-19 pandemic has further exacerbated these challenges. On April 1, 2020, there were country-wide school closures in 194 countries impacting 1.59 billion learners, representing more than 91 percent of the world’s total enrolled students.[4] Beyond the unprecedented disruptions to learning, the potential devastating longer-term implications on children’s well-being and learning are vast. While much about this crisis remains uncertain, it seems inescapable that it will have lasting negative impacts on children’s right to quality education and deepen inequities. Even prior to the COVID-19 crisis, the pace of change was insufficient to address these challenges. It is estimated that at current rates, by 2030, only 89 percent of children will complete primary school globally, 81 percent lower secondary school, and just 58 percent upper secondary school, falling far short of the 100 percent target.[5] Meanwhile, school completion is only one component of achieving Sustainable Development Goal (SDG) 4—inclusive and equitable quality education and lifelong learning opportunities for all. And these projections have not yet taken into account the additional challenges stemming from the current pandemic. The scope and depth of these challenges and the reality of how far we are from achieving SDG 4 clearly demonstrate that “business as usual” approaches will not work. Countries need to identify, scale, and sustain effective approaches in order to address the magnitude of the learning crisis and transform education systems to meet the needs of all children, especially the most marginalized. Scaling quality education programs requires more than simply identifying effective initiatives; it takes a combination of technical and political strategies, mechanisms to accelerate the adoption of new practices, and strengthening of local capacity for successful adaptation and scale. In response to this gap, the Center for Universal Education (CUE) at Brookings launched a series of Real-time Scaling Labs, in collaboration with local institutions in a number of countries, to generate more evidence and provide practical recommendations around the process of scaling impact in education. Over the course of five years (2018—2023), this action research project is accompanying initiatives at various phases of scaling in order to learn from, support, and document the process as it unfolds. The following brief provides a synthesis of emerging insights and learning from the Real-time Scaling Labs to date (June 2018-June 2020).

Deep-rooted, global education challenges that the COVID-19 pandemic has exacerbated—learning inequalities between and within countries, youths dropping out of school, and students in school but not learning—require transforming education systems at large scale to meet all children’s needs. While innovative solutions are being tested in every corner of the world, too many of them remain small. The key question is how to identify, adopt, and adapt what works and bring that to more communities with lasting impact. How can these efforts be effectively, equitably, and sustainably scaled to ensure more children are learning? In response to these questions, the Millions Learning project at the Center for Universal Education (CUE) launched a series of Real-time Scaling Labs (RTSLs) with local institutions in several countries to generate more evidence and practical guidance for policymakers, practitioners, and funders on how to scale evidence-based education initiatives. To provide concrete guidance based on key scaling principles and respond to gaps identified through the RTSLs, CUE has developed the following scaling-related tools[1] in collaboration with lab partners and other colleagues. Based on empirical research, these resources are designed to foster an iterative, reflective, and data-driven scaling process, with each tool supporting different phases of the scaling journey.

Scaling – expanding and deepening the impact of an initiative – often seems like it should be common sense. When a simple, impactful, cost-effective solution to a pressing problem is developed, how can it possibly not take off and reach many more people and places? Why wouldn’t everyone immediately jump on expanding an effective innovation? In reality, however, scaling is much more complex, and a myriad of both technical and political factors can prevent even the best innovations from scaling their impact. Take the case of improved cook stoves. Nearly 3 billion people cook food and heat their homes with stoves fueled by wood, coal, or animal dung, whose harmful fumes can cause serious health issues. Yet despite decades of initiatives to get improved cooking stoves into the hands of the poor, scaling up usage has been remarkably slow. In India, for example, one study found that despite families receiving such stoves almost for free, many did not actually use the stoves, preferring to cook with traditional methods that better suited their needs, or used both old and new stoves simultaneously, diminishing the health benefits. Scaling demands much more than just a better stove design; it requires considering a whole host of complex technical, political, and social factors that may at first glance seem tangential to the stove itself. “A myriad of both technical and political factors can prevent even the best innovations from scaling their impact.” Similarly, scaling in education is far from straightforward. Over the past 150 years, the expansion of schooling has been hailed as one of the most successful scaling stories, with tremendous progress in access made in the past two decades alone. Between 2000 and 2015, primary school enrollment in developing countries rose from 83 percent to 91 percent and the number of out-of-school children worldwide fell by almost half, from 100 million to 57 million. In spite of these successes, the scaling of children’s learning and the development of core competencies has not kept pace with increased enrollment. Today, more than 387 million children of primary-school-age and 230 million adolescents are not achieving minimum proficiency levels in reading and math. UNESCO reports that “the vast majority of children and adolescents who are not learning are in school,” so we know that simply getting kids in a classroom is not enough.

The last two decades have been marked by a significant increase in the number of children who have access to schooling. Yet, millions of children still lack the opportunity to attend school and those that do are often not learning. This growing recognition of the “global learning crisis” has coincided with a proliferation of innovations in education with the potential to complement effective existing practices, displace ineffective ones, and ultimately accelerate improvements in learning. To effectively leverage these innovations, it is critical to identify those which hold potential, test them in a specific context and, depending on the results, adapt and scale them to other contexts. In an effort to support this cycle, UNICEF and the R4D’s Center for Education Innovations (CEI) launched the Innovations in Education Initiative. In 2014, 162 programs applied to receive financing from UNICEF and technical support from both organizations. Five programs were selected as finalists based on a number of criteria, such as equity, learning, access, and systems strengthening. Journeys to Scale accompanies these innovations from Brazil, Ethiopia, Ghana, Peru, and Sudan, as they strive to increase their impact. Drawing from the challenges faced and strategies employed to overcome such hurdles, it lays out clear recommendations for implementers, donors, policymakers and researchers who want to support innovation.

It has become cliché to assert that there is no silver bullet to improve education outcomes at scale (is anyone actually arguing that there is a silver bullet solution?). But education innovations are consistently being surfaced — and some do show evidence of producing quick results. How thus should we reconcile the promise of new approaches with the more sobering understanding that each alone is unlikely to dramatically alter macro-learning trends? This is what we’ve been asking ourselves as we enter our fifth year of running the Center for Education Innovations (CEI). We’ve built a global network of over 750 education innovators in over 100 countries and provided a platform for them to share their work and connect with each other. But we are increasingly focused on thinking about how those innovators can play a role in changing the broader education systems to which they belong. We fundamentally believe that education systems that incentivize, seek out, and support innovation will see those macro-level trends changing before others. To us, “innovation” doesn’t mean technology (but it can), it doesn’t mean contracting to the private sector (but it can), it simply means altering the status quo and trying something new — so it shouldn’t be a terribly provocative statement that innovation is needed to strengthen education systems. But what does that look like? It is no easy task, given that education systems are dynamic entities, made up of a complicated web of financial, human, pedagogical, governance, and operational inputs. Creating pathways for innovation within such an ecosystem requires a combination of careful planning and strong leadership; even then, shifting priorities of education ministries, lack of financing, and other roadblocks can derail the best intentions. But it’s not all bad news. Our engagement with policymakers, donors, and members of the CEI community who have either nurtured innovations within government education systems or partnered with government as a pathway to scale have revealed three key lessons.

Start small but think big. That is an attractive approach to innovation and reform for education in Africa, where available resources often cannot meet expanding demand, schools are underequipped, well prepared teachers and effective instructional materials are in short supply, and quality remains uneven across the country and among different segments of the population. Begin with an initial effort in a particular school or district. Prepare the ground well, with careful planning, extensive communication among those involved, and adequate funding. Monitor and assess the results. Modify the practice to respond to local settings and in light of preliminary outcomes. Then, as it becomes clearer what has worked and what has not, expand the pilot to other settings. “Go to scale.” Eventually the entire education system becomes the site for the reform. “Going to scale” has been the advice and the injunction in African education for several decades, both within and outside the continent. For national educators, enlarging an effective small scale innovation is an attractive strategy for broader reform. Beginning with a pilot focuses attention and energy, provides a controlled testing ground for trials and assessment, limits the risk should an initiative prove unviable, and establishes the pattern that can subsequently be replicated throughout the country. The challenge of scaling up, however, has proved difficult to achieve. There are apparently few documented cases of pilot education reforms in Africa that have been effectively scaled up to become nation-wide programmes. Indeed, some very promising initiatives have proved difficult or impossible to sustain, even at their small scale, after the departure of their initial leaders or the end of their initial funding. Accessible systematic empirical research on scaling up promising education initiatives in Africa is unfortunately quite limited. Most of the literature is normative and anecdotal. One result is that contemporary discussions of scaling up are eerily repetitive, with little apparent attention to why more than two decades of insistence on the importance of scaling up has not led to more and more effective scaling up. Addressing efforts to scale up requires recognizing that some initiatives may be viable precisely because they are small. Responsive to local needs and demands, well adapted to a local setting, and guided, managed and perhaps funded by the local community, reforms of that sort flourish where they are nourished and wither where they are not. Attempting to enlarge their scale would be like scattering seeds on sun-baked hard unyielding soil that has not been loosened by rain and plow or planting a crop that requires strong sun in the perpetual shade of a hillside forest

Young people between the ages of 10 and 19 make up 23% of Pakistan's population. In Pakistan, young people face many challenges in terms of sexual and reproductive health (SRH) issues. These include early marriage and pregnancy, low use of contraception, use of unsafe abortion, lack of relevant information and poor knowledge about bodily development including puberty and menstruation, sexuality, reproduction and HIV. This paper examines the scale-up of a rights-based, life skills-based education programme during the period from 2004 until 2013, which included comprehensive education about SRH issues. The programme was introduced by Rutgers WPF Pakistan in a total of 1188 schools. Introduction and scale-up were made possible by a combination of attributes among the organisations leading the development of the programme and the users. The main challenge, which related to the conservative operating environment in which the programme was first introduced, was addressed through a multiplicity of media and advocacy activities in the community, among parents, and by involving teachers, school administrators, district education departments and Muslim scholars in the development and review of the curriculum. The scale-up of a comprehensive sexuality education programme that targets young people in a conservative Muslim country is possible when there is careful curriculum design and materials and approaches are developed in close collaboration with key stakeholders. young people life skills sexual and reproductive health Pakistan scale-up

Those who set out to change schools and schooling are confronted with two enormous tasks. The first is to develop prototypes. The second involves large-scale replication. One without the other is insufficient. Yet considerably more attention is paid to developing and validating prototypes than to delineating and testing scale-up processes. Clearly, it is time to correct this deŽciency. The ideas presented in this article are meant to stimulate work on the problem and thereby to advance the cause of educational reform. Finally, in fairness to those who labor for educational reform, we all must remember that the quality of schooling, family life, and community functioning spirals up or down as a function of the quality of the ongoing transactions among each. Thus, scale-up efforts related to educational reform must take place within the context of a political agenda that addresses ways to strengthen the family and community infrastructure through strategies that enhance economic opportunity, adult literacy, and so forth. What we need are policies that develop, demonstrate, and scale-up comprehensive, multifaceted, integrated approaches that can effectively address barriers to development, learning, and teaching.

Technology has great potential to help address critical challenges facing global education today: the lack of access to school for millions of children globally; the lack of access to quality education for those children who do make it to school; and the challenge of ensuring that education supports the development of skills critical for jobs, livelihoods, and life choices. Unsurprisingly, as previous articles in this series have highlighted, there is no technological silver bullet solution to any of these challenges. But an area where technology could have the most impact is for children who are out of school and are unlikely to have access to formal education opportunities. These are children who may be affected by war, migration, or early marriage, or may need to work to contribute to their families’ economic wellbeing. Many private and public sector organizations are now turning to technological initiatives in the hope of addressing the huge needs of children losing out on an education as a result of conflicts such as the Syrian crisis. One of these initiatives is Can’t Wait to Learn (CWTL), a program led by youth aid NGO War Child Holland that uses educative gaming on tablet computers to bring a digitized version of learning curricula for literacy and math to children affected by conflict. Two pilots of the program, then called eLearning Sudan, in three states between 2013 and 2015 found that participating children scored an average of 20 and 31 percentage points, respectively, higher in math than children in the control group. The pilots also indicated positive effects on children’s self esteem. CWTL then tested the program among marginalized children across Sudan and again found that it helped children learn math successfully and quickly. Based on this success and the urgency of the humanitarian need in the Middle East, the IKEA Foundation, the Dutch National Postcode Lottery, UNICEF, and others have funded CWTL to scale up in that region.

This white paper calls upon education-sector stakeholders to ensure that every child in Nigeria benefits from successfully tested education interventions by focusing on efforts to scale up their impact. There is no lack of innovations1 in Nigeria that demonstrate how education quality and access can be improved. The problem is that although project implementers and researchers may hope for large-scale adoption of successfully tested innovations, typically they are not expanded to reach larger student populations and rarely are institutionalised in policies and programmes. In cases where expansion or institutionalisation has been achieved, the systematic process adopted is often unclear or undocumented. Much has been learned over the last several decades about what makes scale up succeed. Frameworks as well as guidance now exist to support implementers and decision makers who wish to ensure large-scale and lasting impact of innovations. This white paper describes a general approach, and related guidance tools, that have been used by a number of education sector actors in Nigeria to enhance the likelihood of scale-up success. It highlights key challenges faced in scaling up educational innovation in Nigeria and proposes a process to help overcome them. The paper argues that systematically designing and implementing projects with scaling up in mind, and strategically planning and managing the scaling-up process, will lead to greater promise of achieving the Sustainable Development Goals for education. Keywords: education, scaling up, innovation, guidance, expansion, institutionalisation

The Hewlett Foundation commissioned Management Systems International to conduct a formative evaluation of the Early Learning Innovation Fund, which began in 2011 as part of the Quality Education in Developing Countries (QEDC) Initiative, a partnership between the Hewlett Foundation and the Bill & Melinda Gates Foundation. This report is part of a series of evaluations of the QEDC Initiative. The Early Learning Innovation Fund seeks to: promote promising approaches to improve children’s learning; strengthen the capacity of organizations implementing those approaches; strengthen those organizations’ networks and ownership; and grow 20 percent of implementing organizations into significant players in the education sector. The Fund directly supported two regranting organizations, Firelight Foundation and TrustAfrica, which in turn supported 12 community based organizations in Tanzania, and 16 early learning and childhood development organizations in four countries (Senegal, Uganda, Kenya, and Mali), respectively. The evaluation, which began at the end of 2014, offers a mid-term assessment of the extent to which the Fund has achieved its intended outcomes, as well as the factors that have limited or enabled its achievements. It provides the Hewlett Foundation and other funders interested in supporting intermediary grantmakers, early learning innovations, and scaling those innovations insight into best practices in these areas, and is also intended to inform planning for Phase II of the Fund. The evaluators analyzed the support the intermediary regranting organizations provided to the organizations they supported with grants from the Fund, with a specific focus on monitoring and evaluation. This final evaluation report contains recommendations in four key areas: allowing adequate time for both the regrantors and ultimate grantees to achieve realistic project implementation; focusing explicitly on regrantors’ capacity-building strategies in the initial call for proposals and establishing standardized institutional assessment tools that will permit monitoring institutional change over time; requiring specific strategies from regrantors for scaling up innovations, with reference to national-level stakeholders in the work such as ministries of education; and clearly communicating expectations of regrantors regarding monitoring and evaluation.

This viewpoint article argues that there is an urgent need to reform the projectbased EdTech approach in order to allow EdTech to contribute to the resilience of education systems in the aftermath of Covid-19. Looking at the contrast between the multiplication of EdTech pilot projects presented as a necessary step in a process that will eventually lead to scaled solutions and the lack of solutions that actually scale, the article highlights those long-standing issues perceived as most pressing by the actors involved in projectbased EdTech initiatives. Their perspective and statements allow one to grasp how the EdTech project approach favors the setup of EdTech projects that are by design unscalable, driven by a utopian perception of scalability and instrumentalized in the name of a goal that is de facto only a branding. As a result, and despite the mobilization of tremendous resources, the EdTech project-based approach cannot be system-transformative. Keywords Education Planning EdTech · Project-based approach ICT4D ICT4E Scalability

In the United Kingdom there are nearly 4 million children living in poverty. This alone has a disproportionate effect on their chances in school, in learning and in life. In 2002, while working as a management consultant, I was tasked to look into why children from low-income backgrounds were under-performing in London’s schools. What I discovered was shocking. I couldn’t find a single London school with a majority low-income intake that was meeting the national grade averages. It was clear what was needed to turn this around: leadership in these classrooms—and beyond. This led me to found Teach First—the education and social mobility non-profit that this year celebrates its 15th anniversary. We have a simple but powerful vision—that no child’s educational success should be limited by their background. We find and develop great people to become part of our movement of leaders across schools, education systems, and society who are all working to tackle this issue, starting with our two-year Leadership Development Progamme. Since 2002, we have scaled rapidly. Our first intake of trainees was 182-strong. Last year, we recruited over 1,400 trainees, making up a quarter of new teachers in low-income schools in England. We’re now one of the U.K.’s largest graduate recruiters, having hired more than 10,000 in total. Collectively they’ve helped support over 1 million pupils, and we now cover almost every area of England and Wales. Most importantly, however, we now have proof that our approach works. Independent analysis shows our teachers increase pupils’ grades, and are seven times more likely to be in senior school leadership positions than teachers who train via other routes. Beyond teaching, other former trainees are founding social enterprises, leading business engagement with schools, and advocating for change in policymaking. Teach First has grown at a rate of approximately 20 percent a year, making us one of Britain’s fastest-growing non-profits. As I reflect on the last decade-and-a-half, there are four approaches that stand out as to why we’ve been able to grow so quickly. Many of these are reflected in the Center for Universal Education’s Millions Learning report on scaling up quality education interventions:

While there are many different pathways to scaling and sustaining the impact of a development initiative, the reality is that in the education sector, delivering at scale over the long term is very often not possible without government in the lead. When an NGO, social enterprise, or donor develops and implements the initiative first, the scaling strategy must center around the gradual transition to government ownership, delivery, and financing—assuring quality and impact are maintained.

A growing body of research has shown that financial inclusion can be a powerful tool for addressing economic growth, poverty reduction, and gender and income inequality. Yet there are also risks associated with financial services, and thus, it is important for financial inclusion to be accompanied by efforts to improve financial literacy. Early exposure to financial knowledge and skills is particularly important for helping youth manage complex financial decisions and develop healthy long-term financial behaviors.

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.

January 24th marks the annual International Day of Education—a moment to reaffirm our global commitment to the rights of every child to a quality education. Teachers are perhaps the most important actor in a child’s education—a significant body of research demonstrates that high-quality teaching is one of the biggest factors impacting student learning. In the United States, for example, studies have found that the differences between a good and a bad teacher can equate to a full year of learning for a student. Quality teaching also can play a role in improving equity, as “several years of outstanding teaching may in fact offset learning deficits of disadvantaged students.” This means that the quality and effectiveness of education, training, and continuous professional development for teachers and other members of the education workforce should be a top priority for those working to strengthen quality learning opportunities for all. The outsized impact of teachers on student learning makes it clear that successfully improving learning outcomes at scale will require reckoning with how to scale teacher professional development (TPD) in an effective, efficient, and equitable way. As a global education community, we need to learn more about how to sustainably scale quality teacher training opportunities; otherwise, we risk stymying efforts to scale improved learning outcomes more generally.

Globally, more than 570 million households farm small plots of land to earn income. Traditional agricultural extension models that provide in-person advice to smallholder farmers are expensive, difficult to scale, and do not deliver the customized and timely information farmers need to adopt potentially profitable farming practices. Research from India and Kenya has shown that mobile phone-based extension can be an efficient and cost-effective way to deliver tailored and timely agricultural information to farmers to promote behavior change that can increase farmers’ yields and incomes. Building on this evidence, Precision Agriculture for Development (PAD) was founded in 2016 with a mission to diffuse extension advisory and support smallholder farmers in low- and middle-income countries with information delivered via their mobile phones. PAD (now Precision Development or PxD) continues to use research and learning to scale—now reaching over 5.2 million farmers in ten countries with evidence-informed mobile extension services, as of the third quarter of 2021.

Commercial seed delivery for smallholder farmers in many parts of sub-Saharan Africa has been limited to few crops and varietal turnover has been slow. Publicly funded breeding needs to engage with seed systems in order to deliver greater genetic gain in farmers’ fields via varietal replacement. This White Paper was commissioned by funders of the Crops to End Hunger (CtEH) initiative in the context of the ongoing One CGIAR reform to identify approaches and make recommendations that will both diversify the range of public-bred crop varieties available to smallholder farmers and increase varietal turnover through commercial channels. An expert consultation identified 14 bottlenecks to commercial seed delivery. These can be broadly classified into policy and regulatory barriers hindering variety release, insufficient understanding of target markets, lack of technical and business capacity of small and medium seed enterprises (SMEs), and the need to better define roles and responsibilities between One CGIAR, National Breeding Programs (NBP) and commercial seed companies in a changing landscape. A product life cycle (PLC) approach was used to categorize the bottlenecks and then to identify solutions. The PLC is useful to: (i) describe when bottlenecks in the deployment of publicly bred varieties occur; (ii) identify possible interventions; (iii) more clearly define the roles of partners, and (iv) monitor progress through the stages.

As climate change threatens India’s food security, adaptation in the agriculture sector is becoming increasingly important. However, for too long, adaptation has been characterized by individual efforts and by small, time-bound pilot projects. Although these projects often have a strong grassroots focus, their capacity to benefit larger populations and to contribute to policy reform is limited (Reid and Huq, 2014). In India, scaling adaptation is of particular importance in rainfed agricultural areas, where crops depend on monsoon rains. Projections indicate that, without adaptation, climate change will stress rainfed agricultural systems, with potentially significant decreases in yield and a loss in farm-level net revenue of between 9 percent and 25 percent in the South Asia region (Manava and Robert, 2011). This report aims to accelerate scaling of adaptation in rainfed India by providing a framework to enable project implementers, funding agencies, and policy makers to identify good adaptation practice, determine what is ready to be scaled, and understand the process of scaling and the conditions necessary to support it. The authors applied the framework to twenty-one adaptation projects and conducted four deep dive case studies to assess the scaling potential of adaptation projects in rainfed regions of India.

The COVID-19 pandemic has brought the world to a tipping point or a turning point in the fight against climate change. Decisions taken by leaders today to revive economies will either entrench our dependence on fossil fuels or put us on a path to achieve the Paris Agreement and the Sustainable Development Goals (SDGs). For the COVID-19 pandemic to prove a turning point, climate action and COVID-19 economic stimulus measures must be mutually supportive. Developing countries must be able to access long-term affordable finance to develop and implement green stimulus measures.

The question of how small and medium enterprises (SMEs) in the agri-food sector successfully develop and grow their business is a matter of high practical and theoretical relevance. The current paper conducts a systematic literature review focused on two key objectives. First, it explores the conceptual underpinning and evolution of the scaling concept by analyzing relevant conceptual and empirical journal articles. Second, the paper identifies and systematizes the key scaling strategies, drivers and mechanisms implemented by agri-food SMEs by reviewing published business case studies. The study’s findings reveal that agri-food SMEs primarily utilize vertical scaling up, which is achieved through establishing partnership relations, collaboration and integration mechanisms. Horizontal scaling out is another frequently used strategy accomplished via market demand stimulation, product diversification and geographic expansion. In contrast, scaling deep is the least frequently used strategy, which is achieved through transformative learning and cultural mechanisms. Overall, the results contribute to the literature on scaling agri-food SMEs by providing a comprehensive overview and classification of the key strategies, drivers and mechanisms used by agri-food SMEs.

Scaling is a ubiquitous concept in agricultural research in the global south as donors require
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.

If the success of Asian countries in transforming their rural economy is measured by the extent to which poverty has declined over the past 20 years, there is no question that their transformation can be regarded as one of the major achievements in human history. The decline in extreme poverty and hunger has been outstanding and today Asia is making steady progress towards eradicating both by 2030. Contrasting with these bright lights, though, are shadows dimming Asia’s development performance. Environmental quality has worsened and continues to do so at a rapid pace. The degradation of natural resources has reached worrying levels in most parts of Asia. Vulnerability to climate change is increasing as concentrations of CO2 in the atmosphere increase. Inequality is on the rise, both within rural and urban areas and between them. New problems are overtaking the older ones and Asia is now entering a critical part of its history. Agenda 2030 and the Sustainable Development Goals are challenging propositions for today’s policymakers in Asia.

This Scaling Brief was developed by CGIAR Science Leaders and scaling specialists to provide guidance in the design and implementation of scaling within the CGIAR initiatives (see Brief #1 for more background information). Its purpose is to support scientists and research managers in operationalising scaling interventions that adequately address the scaling principles introduced in Brief #2. These principles align well with the scaling needs commonly identified by scaling practitioners in the context of the CGIAR (Table 1). This calls for scaling tools and holistic scaling approaches (meaning integrated sets of tools and procedures for scaling activities in different contexts). These tools and approaches help to address the multidimensional factors that must be considered if scaling is to produce a useful and responsible impact. They also help to manage scaling related interventions. Professionalising the manner in which technical, social, governance innovations are scaled up is essential if the ambitious goals of the One CGIAR are to be achieved1 . Available scaling approaches and tools do offer solutions for various needs (Table 1), but they differ in their scope, depth and intensity of use. Key features – and differences – of a selection of approaches and tools that are (or potentially could be) used widely in and beyond One CGIAR are listed below. Additional options and information about the practical and scientific aspects of scaling are referred to in the Annex.

In the second webinar, Johannes Linn from the Brookings Institution and Timothy Krupnik,
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.

In the third webinar, Ndidi Nwuneli, Co-Founder of Sahel Consulting: Agriculture & Nutrition Ltd., and Ram Dhulipala, Theme Leader – Digital Agriculture & Youth at the International Crops Research Center for the Semi-Arid Tropics (ICRISAT), presented examples of successful scaling by private sector actors in Africa and Asia, examined what has proven to be critical for success, and discussed important pitfalls. They also examined the role of big data in getting to scale and for monitoring at scale–both quantitatively and qualitatively.

In the first webinar, Hayley Price-Kelly, Evaluation Program Officer of IDRC, and Marc Shut, Senior Innovation and Scaling Scientist at IITA, answered the following questions: What is the science of scaling and what have we learned so far? What critical knowledge gaps are yet to be filled? What are the roles and responsibilities of researchers and research for development centers, and how can development and research organizations learn from each other for sustainable change at scale?

1. Pursue a shared vision of change Reach a shared understanding with partners and other stakeholders about how they want agri-food systems and rural areas to be. Then agree on intended outcomes and impacts, e.g. for whom, where, when and with whom that vision can be achieved. Next, develop a shared understanding about what must be scaled by assessing the scalability of different innovations for various contexts and beneficiaries (see Brief #3). Determine how the scaling pathway and process must look if the intended changes are to be achieved in a sustainable and responsible manner. Recognise the fact that in dynamic situations, we can only make improvements and not permanent fixes. Available tools and approaches related to scaling and systems thinking help us to accommodate and integrate different perspectives, unravel complexity, broaden options for action and identify leverage points (see Brief #3). All the solutions must be based on the needs of various stakeholders and on their practices, beliefs, aspirations and financial means. This will enable the solutions to be embedded in local systems after a project ends. However, you may have to deal with friction, conflict, disruption and consensus building among different stakeholder groups. Other requirements are: building on previous interventions, aligning with other initiatives and seeing your project as a piece of the puzzle that addresses parts of the system for a limited period of time – and while you move towards these goals, remember that your ultimate aim is to achieve the shared vision of change...

Anthropogenic carbon emissions have the potential to trigger changes in climate and ecosystems that would be catastrophic for the well-being of humans and other species. Widespread shifts in production and consumption patterns are urgently needed to address climate change. Although transnational agreements and national policy are necessary for a transition to a fully decarbonized global economy, fluctuating political priorities and lobbying by vested interests have slowed these efforts. Against this backdrop, bottom-up pressure from social movements and shifting social norms may offer a complementary path to a more sustainable economy. Furthermore, norm change may be an important component of decarbonization policies by accelerating or strengthening the impacts of other demand-side measures. Individual actions and policy support are social processes—they are intimately linked to expectations about the actions and beliefs of others. Although prevailing social norms often reinforce the status quo and unsustainable development pathways, social dynamics can also create widespread and rapid shifts in cultural values and practices, including increasing pressure on politicians to enact ambitious policy. We synthesize literature on social-norm influence, measurement, and change from the perspectives of psychology, anthropology, sociology, and economics. We discuss the opportunities and challenges for the use of social-norm and social-tipping interventions to promote climate action. Social-norm interventions aimed at addressing climate change or other social dilemmas are promising but no panacea. They require in-depth contextual knowledge, ethical consideration, and situation-specific tailoring and testing to understand whether they can be effectively implemented at scale. Our review aims to provide practitioners with insights and tools to reflect on the promises and pitfalls of such interventions in diverse contexts.

Scaling up innovations and solutions in agriculture was discussed in the September 2018 conference, Innovations in Agriculture: Scaling Up to Reach Millions, organized by Purdue University, in partnership with the African Development Bank. The Scale Up Sourcebook is a collection of contributions at the said conference and also aims to capture methodologies for leveraging globally the technology and innovations designed to improve food security, nutrition, and livelihoods in the developing world. The publication distils the expertise, ground-breaking innovations, and examples of successful scale on display at the conference, will surely serve as a valuable guide for those driven by the imperative to revolutionize African agriculture. It is intended as an easy-to-use guidebook targeted to a broad and diverse audience of stakeholders associated with scaling agricultural technologies and innovations to meet the needs of the world’s poor. The Sourcebook has following chapters: designing with scale in mind; assessing scalability; using commercial markets to drive scaling; financing the transition to scale; creating an enabling environment for scale; tailoring metrics, monitoring, and evaluation to support sustainable outcomes at scale; and the critical role of intermediary and donor organizations. Also summarized in the Sourcebook are many of the growing array of on-the-ground cases, donor practices, and analytic tools that can help to inform future efforts to scale agricultural interventions and outcomes. Topics: Technologies Applied ICTs decision-makers extensionists government partners

Since 1998, the World Agroforestry Centre, in collaboration with a range of partners, has been developing a participatory approach to domestication of indigenous trees. Tree domestication, defined as an accelerated and human-induced evolution to bring species into wider cultivation through a farmer-driven or market-led process, aims to diversify smallholder farming systems through the cultivation of indigenous trees. A major research topic has been the adaptation of the tree domestication process to farmer conditions. Hereto, experiments on selection and propagation of superior trees, their integration in farmers’ fields and the marketing of trees and tree products have been carried out with farmer groups in pilot sites. Today, the challenge is to develop ways to extend tree domestication options to other communities. Therefore, different scaling-up approaches are evaluated for efficiency. One of the approaches tested is to assist NGOs and other extension services in the dissemination of tree domestication techniques by providing them with knowledge and logistical support. Another method is to build training capacities of farmer leaders, so that they diffuse the innovations further. In both cases, the first step is to set-up a resource centre where farmers come to discover and experiment with the new technologies, before taking the skills back to their own communities. Thirdly, through active participation in strategic meetings and media exposure, ICRAF is trying to put tree domestication on the agenda of development and conservation organisations, which are searching for innovations to raise farmers’ income in an ecologically friendly manner. Results obtained so far indicate that the success of any of the scaling-up methods depends in the first place on the motivation and commitment of the partners, in addition to their financial and human capacity. Lastly, experience in the field shows that none of the scaling-up mechanisms alone can reach the level of adoption required to impact on farmers’ lives and the environment at larger scale. Therefore, a winning scaling-up strategy for tree domestication must essentially be a combination of the dissemination pathways described above, probably in addition to others.

Investments in process-oriented and farmer-participatory research have led to the emergence of sustainable agroforestry solutions to the problems of land degradation, poverty, and food insecurity in rural areas. Thousands of farmers in diverse ecoregions have taken up innovations that demonstrate the potential of agroforestry. This paper highlights the importance of institutional change through illustrating the approach taken by the International Centre for Research in Agroforestry to scale up adoption and impact of innovations. Eight focal areas of intervention constitute the key elements of a development strategy aimed at providing 80 million poor people in rural areas with better livelihood options by 2010.

• CRS presented an overview of their Livelihood and Landscape Restoration Strategic Change Platform with a deeper dive into Lesotho’s Integrated Catchment Management Program. CRS is scaling a common set of principles and proven land restoration models (watershed management, dryland regreening, multistory agroforestry and water-smart agriculture) that improve agricultural production, and increase food security, income and resilience. The Platform is currently operating in 8 target countries – four in a regional approach in Central America and 4 countries in Africa. All four land restoration models are represented across these countries. Besides the target countries, CRS is developing tools and methodologies for cross learning and support to a number of non-target countries in Africa and Asia. Some of the key elements of their scaling approach include building capacity and empowering local leadership, collaboration through multistakeholder platforms, supporting and catalyzing systems change, helping partners to leverage finance, and linking to national and local goals.
• 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.

The reckoning in 2030 on the Sustainable Development Goals is just around the corner, and once again the mid-term monitoring is a cause for concern. The recently published Sustainable Development Report 2022 comments on slow and steady progress until 2019, followed the previous report by two years without discernable improvement. The dashboards show a sea of red status indicators and horizontal arrows signifying significant or severe challenges and a lack of progress, including for key SDGs such as SDG 1 (no poverty), SDG 2 (zero hunger) and SDG 15 (life on land).

Since 2010, USAID’s Development Innovation Ventures (DIV) program has supported over 225 innovations in 47 countries. DIV operates by investing in innovators and researchers to test new ideas, build rigorous evidence of impact, take strategic risks, and advance the best solutions to development issues. DIV contracted USAID’s Learning, Evaluation, and Analysis Project (LEAP III) to provide a status update on innovations, to assess the drivers of successful scale journeys, and to pilot a new conceptual framework to review and assess the success of funded innovations. This independent review elucidated key elements of success and lessons from failure from the scale journeys of DIV-funded innovations and to apply them to DIV programming to improve grant selection and maximize the success rates of supported innovations to achieve impact. DIV is intentionally designed to take a portfolio approach, which is reflected in DIV’s investments in innovations occupying similar spaces. This review covers DIV’s portfolio of grantees in the digital agriculture sector, meaning those for which their core innovation fell within the agricultural sector and had a significant digital component. DIV funded 12 digital agriculture grants between 2010 and 2020, totaling $4,663,237 of DIV funding (Figure 1). See Annex 1 for a description of each grant. Of the 12 digital agriculture innovations funded by DIV, seven were confirmed as on the market in 2021, two were confirmed off market, and three could not be confirmed.

This paper assesses recent lessons in scaling up agroforestry benefits, drawing on three case studies: fodder shrubs in Kenya, improved tree fallows in Zambia and natural vegetative strips coupled with the Landcare Movement in the Philippines. Currently more than 15 000 farmers use each of these innovations. Based on an examination of the main factors facilitating their spread, 10 key elements of scaling up are presented. The key elements contributing to impact were a farmer-centered research and extension approach, a range of technical options developed by farmers and researchers, the building of local institutional capacity, the sharing of knowledge and information, learning from successes and failures, and strategic partnerships and facilitation. Three other elements are critical for scaling up: marketing, germplasm production and distribution systems, and policy options. But the performance of the three case-study projects on these was, at best, mixed. As different as the strategies for scaling up are in the three case studies, they face similar challenges. Facilitators need to develop exit strategies, find ways to maintain bottom-up approaches in scaling up as innovations spread, assess whether and how successful strategies can be adapted to different sites and countries, examine under which circumstances they should scale up innovations and under which circumstances they should scale up processes, and determine how the costs of scaling up may be reduced.

The problem of low and slow adoption of agricultural research innovations by smallholder farmers is very complex and is slowing agricultural modernization processes in developing countries. This has significant impacts on farm productivity and farmers’ livelihoods and affects the returns on investments of national and international agricultural research projects. The situation is further aggravated by changing and challenging climate and social contexts, and so system transformation and modernization has become urgent in order to produce more food, but in a sustainable way. To encourage scaling up and out of research outputs, ‘research for development’ (R4D) projects, which involve the design of appropriate ‘impact pathways’ for agricultural research projects, have become increasingly popular. Additionally, there is a greater focus on scalability, scaling processes, and analytical tools that help to track and monitor technology scaling through research projects. Within these frameworks, ‘appropriate partnerships’ for scaling, consideration of ‘development impacts and outcomes’ during the early stages of project design, ‘demand-driven and response research’, and engagement with private sector, are all important concepts.

Scaling up is not new to the GEF and in the last decade, all GEF focal areas have been shifting from site-level pilot projects towards projects or programs implemented at higher scales. Based on a review of focal area strategies and interviews with the GEF partnership, the GEF has gradually shifted its focus from pilots to scaled-up interventions over the last 25 years. In part, this is because the GEF partnership has built up a much better understanding of what interventions work based on the portfolio of demonstration projects implemented during GEF's early phases. As a more targeted response to the need to achieve impact at scale, the GEF introduced the Integrated Approach Pilots in GEF-6 and the Impact Programs in GEF-7, which have just begun implementation. However, the conditions under which scaling up has been successful or unsuccessful, and the processes by which impacts are scaled up, have not been systematically assessed. In addition, based on interview responses, there appears to be a varied understanding of scaling up across the partnership and how it is achieved in operational terms.

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.

This review, commissioned by the Department for International Development (DFID) Natural Resources Systems Programme (NRSP) Hillsides Research, had as its objective the identification of appropriate strategies to accelerate uptake of innovations by target farmers, and to provide a framework to guide the formulation of scaling-up mechanisms for these innovations towards the aim of poverty reduction and improvement of livelihoods. The review methodology consisted of key literature consultation, an electronic discussion, a mid-term workshop with various stakeholders (e.g. researchers, NGOs) from Asia, Africa, Latin America and Europe and a detailed case study analysis. It was decided to adopt the terms ‘horizontal’ and ‘vertical’ scaling-up as discussed and defined during the ‘Going to Scale Workshop’ (IIRR, 2000). Horizontal scaling-up is the geographical spread to more people and communities within the same sector or stakeholder group, commonly referred to as dissemination. Others refer to it as a scaling-out process across geographical boundaries. Vertical scaling-up is institutional in nature and involves expansion to other sectors/stakeholder groups, from grassroots organizations to policymakers, donors, development institutions and international investors. Furthermore the review is based on the following overarching definition of the objective of scaling-up: \"more quality benefits to more people over a wider geographical area more quickly, more equitably and more lastingly\" (IIRR, 2000). This definition stresses the importance of a peoplecentred vision to scaling-up. Furthermore it introduces the quality dimension to the definition without neglecting the quantitative dimension and it highlights the importance of time, equity and sustainability, dimensions which are of particular importance in the natural resources management (NRM) context. Few cases of successful scaling-up were encountered in relation to research, where creating impact has largely resided with the development of traditional uptake material at the end of projects, without taking into account the dimensions mentioned above. The majority of research cases took a narrow perspective to scaling-up and emphasized the existence of knowledge and technologies. They saw the challenge in improving the ways to \"get these technologies out\" to the target groups over a wider geographical area (horizontal scaling-up). Many of the development-oriented cases acknowledged the multidimensional nature and complexity of scaling-up, and stressed the importance of institutional processes and learning and the need to include a range of stakeholders from different sectors.

Translating climate data and information for use in real-world applications often involves the development of climate service prototypes within the constraints of pilot or demonstration projects. However, these services rarely make the transition from prototype to fully-fledged, transferrable and/or repeatable climate services – that is, there are problems with upscaling them beyond the pilot/demonstrator phase.

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.

The United Nations 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs) reflect a growing consensus that the central challenge society faces is the need to break the path dependencies of development pathways rooted in 20th-century values and priorities, and to transition to more sustainable and inclusive trajectories of development. At the heart of this agenda is a call not only to improve production and consumption systems, but also to transform the fundamental characteristics of these systems to tackle the underlying causes of inequity and unsustainability. The urgent need for transformation defines the current and future development agenda of the 21st century, and the agriculture and food sectors are pivotal to meeting it.

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.

A key thrust in the implementation of the Bank's new rural development strategy is identifying and "scaling-up good practice investments and innovations in rural development." Historically, successful World Bank projects have been one-time investments without strategies for leveraging projects to a larger scale or to broader coverage to increase efficiency and developmental impact in a country or region. The Bank believes that scaling-up good practices must become an integral part of national rural development strategies to reduce rural poverty and support broad-based rural development. This working paper, written in support of the Bank's rural development strategy, is intended to contribute to the development of a framework for thinking about scaling-up. The paper begins with a review of the literature on scaling-up in rural development and other contexts to develop an understanding of basic concepts and terms. Drawing from the literature review and interviews, the authors develop a working definition of the term scaling-up and a provisional framework for analyzing experiences of scaling-up in rural development. Then, to evaluate the provisional framework, the authors apply it to a few well-documented case studies of rapid scaling-up. The final sections of the paper draw lessons from the application of the framework to the case studies and identify key areas for moving forward to support scaling-up impacts in rural development.

Africa’s food systems are at an inflection point. Food demand in sub-Saharan Africa is expected to at least double between 2015 and 2050. Moreover, income growth and urbanization are driving significant changes in consumer demand, including for more varied, nutritious, and value-added foods. Meanwhile, food security remains a challenge—according to the United Nations Food and Agriculture Organization, every day, 256 million Africans go hungry, 93% of them in sub-Saharan Africa. Production volatility is expected to grow as climate change increases variability and alters growing conditions. These challenges have been exacerbated by COVID-19-related supply chain disruptions and associated economic downturns. Without significant transformation, Africa’s food systems will not be able to meet the growing and changing needs of consumers, increase food security and resilience, and deliver on the promise of inclusive agricultural transformation.

The International Livestock Research Institute (ILRI) works to improve food and nutritional security and reduce poverty in developing countries through research for efficient, safe, and sustainable livestock use. However, translating research outputs into products that can be adopted at scale has been a significant challenge for researchers in ILRI and CGIAR centres. To address this, ILRI through the Impact at Scale (I@S) program has curated and adapted a set of scaling tools and approaches to help researchers address this enduring challenge in their work. ILRI's evolving I@S approach, initially summarised in the 'scaling better, together' scaling framework. It follows a modular approach with three 'tracks': light, standard, and an extended track. The light track is an adapted version of the Scaling Scan tool by the Public-Private Partnerships (PPP) Lab and the International Maize and Wheat Improvement Center (CIMMYT)1, and the Agricultural Scalability Assessment Tool (ASAT) by the United States Agency for International Development (USAID). The light track leads to the: 1) development of a scaling ambition from a stakeholder consultative process, 2) identification of potential opportunities and threats to reaching the stated scaling ambition using the Scaling Ingredients; and 3) developing relevant action pathways to be undertaken.

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.

This report provides summary findings and conclusions from a set of five case studies examining the scaling up of pro-poor agricultural innovations through commercial pathways in developing countries. The E3 Analytics and Evaluation Project conducted the studies and prepared this synthesis report on behalf of the United States Agency for International Development’s Bureau for Food Security (USAID/BFS), as part of the Bureau’s efforts to scale up the impact of the Feed the Future (FTF) initiative. The study’s findings also draw on the results of a one-day workshop at which the Project team presented the case studies and preliminary findings to a group of agriculture and scaling experts. USAID/BFS commissioned this study to produce lessons and, ultimately, guidance for the Agency including its country Missions about what types of innovations and which country contexts are best suited for scaling up through commercial pathways, and to identify the activities, strategies, and support necessary to facilitate successful scaling. The findings are timely as the U.S. Congress recently passed the Global Food Security Act, which will continue support for global food security, resilience, and nutrition. Findings on scaling are very relevant for informing the development of the Global Food Security strategy and implementation guidance moving forward. The Project team worked in collaboration with USAID/BFS to select the five case studies based on criteria designed to give significant variance in terms of types of innovations, country contexts, and scaling strategies used. Each case had to (1) have achieved significant scale, (2) have used a commercial pathway to reach scale, (3) be commercially sustainable, (4) offer clear opportunities for learning about innovations, context, and strategies, and (5) involve a USAID-supported activity in which the Agency had a pivotal role. Some of the cases turned out to be different than what had been expected based on information gathered through desk review and remote interviews. This was particularly true of the case of Kuroiler chickens in Uganda, which nevertheless provided important lessons as a counterpoint to the other cases. The case studies examined the scaling up of innovations in Bangladesh, Kenya, Senegal, Uganda, and Zambia. The Bangladesh case examined scaling up access to agricultural machinery services in southwest Bangladesh, and was driven by the USAID-funded Cereals Systems Initiative for South Asia – Mechanization and Irrigation project. The case study in Kenya concerned the scaling up of Purdue Improved Crop Storage (PICS) hermetic storage bags, which were developed with USAID funding. In Senegal, the Project team reviewed the scaling of a complex package of innovations designed to improve productivity and strengthen the value chain in irrigated rice production in the Senegal River Valley. The USAID-funded Project Croissance Economique led that scaling effort, working in close partnership with the government and several other donors. The Uganda case concerned the scaling up of Kuroiler chickens, a high productivity breed that was developed in India for use by rural farmers. The scaling effort was funded by the Bill and Melinda Gates Foundation and implemented through a partnership between Arizona State University and the Government of Kenya. The Zambia case examined the scaling up of hybrid maize seed between 2005 and 2015 (there had been a first wave of scaling there in the 1980s). While the development of hybrid maize seed in Zambia was supported by the International Maize and Wheat Improvement Center with funding from USAID and other donors, scaling was driven by private seed companies.

Innovation pathways can be defined as a sequence of innovation, going to scale, and implementation at sustainable scale, where innovation is a new product, service or systems change not previously introduced in a specific context. They can take the form of new products or services, institutions, or systems change. Such pathways can play a lead role in transforming agri-food systems in low- and middle-income countries. To get us to our global goals, these pathways have to lead to impact at a scale that matches the size of the challenge. Unfortunately, while there are many proposals in the published and gray literature for integrated, transformative approaches to innovation pathways, few have yet either gone to scale or been implemented sustainably at large scale. Here we assess whether there is evidence to support these proposals about how agricultural innovation pathways should be pursued. In this paper we identify from the literature and case studies 10 potentially key factors for advancing scaling along the innovation pathway: participation, inclusion, leadership, iteration, adaptation, the specific attributes of innovation design, funding models, implementation models, systems change, and partnerships. We test these factors against a collection of innovation and scaling case studies from Bangladesh, Brazil, India, Kenya, Senegal, Uganda, and Zambia. While the cases are somewhat limited in their quantitative measures of successful implementation at scale, the qualitative evidence presented in the cases confirms both the general importance of these factors in action and that their importance varies depending on the innovation and context. While confirmation of the importance of these factors is not surprising in itself, we also demonstrate their specific design and implementation (or absence) in different contexts, how each element contributes to success at large scale, and actionable examples to be applied in practice. The paper concludes that integrating these factors will likely require changes to traditional approaches to development, innovation and scaling in agri-food systems. Specifically advancing along an innovation pathway to large scale will require a commitment of greater resources over longer time horizons. In the absence of greater overall resources, this implies focusing on fewer innovations at each phase and a greater appetite for risk and failure in individual cases, suggesting adoption of a portfolio rather than a project approach in evaluating success. This may lead to more unsuccessful individual efforts, but those will be offset by a few transformative successes which will change the lives of hundreds of millions, if not billions.

After decades of neglect, volatile food prices and the persistence of hunger and malnutrition have brought agriculture and nutrition to the forefront of the international development agenda. As governments, donors, and other key actors deepen their commitments, they are also increasing their focus on how successful development interventions can be “scaled up,” meaning how they can be expanded, replicated, and adapted to new and different contexts, for greater and sustained impact. In late 2011, IFPRI’s 2020 Vision Initiative approached Johannes Linn to develop a set of policy briefs that would contribute to a better understanding of scaling up in agriculture, rural development, and nutrition. The authors and other experts met at a workshop in Washington, DC, in January 2012, to discuss their draft briefs. The resulting series brings together a variety of experiences from around the world, delineates different pathways for scaling up, identifies both the key drivers that push the scaling-up process forward and the key spaces that enable initiatives to be scaled up, and outlines the lessons learned. These briefs were written by a wide range of actors, from local communities and nongovernmental organizations to private businesses and donors. They provide an invaluable perspective on the challenges and opportunities for successful scaling up. We are most grateful to Johannes Linn for conceptualizing and editing this set of briefs, to the authors for contributing their experiences and insights, and to the reviewers for their constructive feedback. It is our hope that the lessons gleaned from this series of policy briefs will help bring to scale development interventions that can truly improve the lives of poor and vulnerable people around the world.

The development and scaling of orange-fleshed sweetpotato (OFSP) during the past 25 years is a case study of a disruptive innovation to address a pressing need – the high levels of vitamin A deficiency among children under five years of age in sub-Saharan Africa. When the innovation was introduced consumers strongly preferred white or yellow-fleshed sweetpotato, so it was necessary to create a demand to respond to that need. This was at odds with the breeding strategy of responding to consumers’ demands. Additional elements of the innovation package include seed systems and nutrition education to create the awareness amongst consumers of the significant health benefits of OFSP. Complementary innovation is required in promotion and advocacy to ensure a supportive institutional environment.

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 study inquires on the outscaling of the microtiller, a machine developed by the Philippine Rice Research Institute (PhilRice) in the 1990s to address the tedious rice land cultivation in the Cordillera highlands of the Philippines. Stakeholders of the project were interviewed, particularly staff members of PhilRice and the Department of Agriculture; representatives of the Central Cordillera Agricultural Programme, PhilRice’s partner organization in developing and promoting the microtiller; and manufacturers and farmers in the area. It was found that while the machine offered a solution to the highly tedious land preparation issue, four key factors affected its scaling: absence of private sector engagement, lack of a business plan for scaling, lack of extension services, and the presence of a more versatile and cheaper competitor. This study provides empirical evidence of the usability of the set of scaling ingredients developed by PPPLab and the International Maize and Wheat Improvement Center to facilitate analysis of scaling of innovations. The findings may inform scaling opportunities and strategies for farm machines by agricultural research and development institutions across the globe.

After decades of neglect, volatile food prices and the persistence of hunger and malnutrition have brought agriculture and nutrition to the forefront of the international development agenda. As governments, donors, and other key actors deepen their commitments, they are also increasing their focus on how successful development interventions can be “scaled up,” meaning how they can be expanded, replicated, and adapted to new and different contexts, for greater and sustained impact. In late 2011, IFPRI’s 2020 Vision Initiative approached Johannes Linn to develop a set of policy briefs that would contribute to a better understanding of scaling up in agriculture, rural development, and nutrition. The authors and other experts met at a workshop in Washington, DC, in January 2012, to discuss their draft briefs. The resulting series brings together a variety of experiences from around the world, delineates different pathways for scaling up, identifies both the key drivers that push the scaling-up process forward and the key spaces that enable initiatives to be scaled up, and outlines the lessons learned. These briefs were written by a wide range of actors, from local communities and nongovernmental organizations to private businesses and donors. They provide an invaluable perspective on the challenges and opportunities for successful scaling up. We are most grateful to Johannes Linn for conceptualizing and editing this set of briefs, to the authors for contributing their experiences and insights, and to the reviewers for their constructive feedback. It is our hope that the lessons gleaned from this series of policy briefs will help bring to scale development interventions that can truly improve the lives of poor and vulnerable people around the world.

The farmer field school (FFS) concept has been widely adopted, and such schools have the reputation of strengthening farmers’ capacity to innovate. Although their impact has been studied widely, what is involved in their scaling and in their becoming an integral part of agricultural innovation systems has been studied much less. In the case of the Sustainable Tree Crops Programme in Cameroon, we investigate how a public–private partnership (PPP) did not lead to satisfactory widespread scaling in the cocoa innovation system. We build a detailed understanding of the key dimensions and dynamics involved and the wider lessons that might be learned regarding complex scaling processes in the context of agricultural innovation systems. Original interview data and document analysis inform the case study. A specific analytical approach was used to structure the broad-based exploration of the qualitative dataset. We conclude that scaling and institutionalization outcomes were impeded by: the lack of an adaptive approach to scaling the FFS curriculum, limited investments and genuine buy-in by extension actors, a failure to adapt the management approach between the pilot and the scaling phase, and the lack of strategic competencies to guide the process. Our findings support suggestions from recent literature that pilots need to be translated and adapted in light of specific contextual and institutional conditions, rather than approached as a linear rolling-out process. These findings are relevant for the further spread of similar approaches commonly involved in multi-stakeholder scaling processes such as innovation platforms.

In this thesis, I look at how during the first decade of the new millennium a publicprivate partnership (PPP) initiative attempted to innovate and to achieve sector transformation. The PPP worked towards the permanent adoption of alternative training approaches, in order to tackle complex sustainability challenges among African cocoa smallholder farmers, and work toward a more sustainable and productive cocoa value chain. In this introductory chapter, I first set out to sketch the background of smallholder cocoa farming in West Africa and the historical context of agricultural extension service delivery in the region. I then concentrate on the set-up of this first of its kind PPP, and on the development of a pilot on the alternative training intervention it sought to introduce and scale. This is followed by the problem statement and research objectives. The theoretical approach outlines how the empirical chapters, two to five, contribute to the current literature, linking back to the analytical focus and research questions. After a discussion of the research design, I conclude this introduction with the outline of the thesis.

Bangladesh has an estimated 1723 square kilometers of newly accreted lands, locally known as char land along the banks of Brahmaputra / Teesta River system in the North and along the southern coastal districts of the country. These transitional char lands in the inland river systems are composed of coarse sands and by definition these belong to the government, but in reality, these are occupied, accessed or used by settlers in the vicinity of these chars for sandbar cropping of food crops. The poor farmers, who are displaced settlers due to recurrent river erosion, produce food crops such as rice, maize, pumpkins, vegetables and fruits and raise livestock animals on these ‘unusable’ lands. Accessing to these marginal lands provides food security and livelihood opportunities for the extreme poor through transforming lands, transforming lives. The innovation comprises the demonstration and widespread adoption in two districts of North West Bangladesh of ‘sandbar cropping’, an innovative, simple, cost-effective technology which transforms silted barren lands created by flooding and, as a result, helps thousands of displaced, extreme-poor families surviving on the edge of mighty rivers to escape from extreme poverty and hunger; climate change and covid19 shocks.

Entrepreneurs are the lifeblood of the agriculture and food sector in Africa, which is projected to exceed a trillion dollars by 2030. This book is the first practical primer to equip and support entrepreneurs in Africa through the process of starting and growing successful and resilient agriculture and food businesses that will transform the continent. Through the use of case studies and practical guidance, the book reveals how entrepreneurs can leverage technology and innovation to leapfrog and adapt to climate change, ensuring that Africa can feed itself and even the world. The book will: - Inspire aspiring entrepreneurs to start and grow resilient and successful businesses in the agriculture and food landscapes. - Equip aspiring and emerging entrepreneurs with practical knowledge, skills, and tools to navigate the complex agriculture and food ecosystems and develop and grow high-impact and profitable businesses. - Enable aspiring and emerging entrepreneurs to develop scalable business models, attract and retain talent, leverage innovation and technology, raise financing, build strong brands, shape their ecosystem, and infuse resilience into every aspect of their operations. The book is for aspiring and emerging agribusiness entrepreneurs across Africa and agribusiness students globally. It will also inspire policymakers, researchers, development partners, and investors to create an enabling and supportive environment for African entrepreneurs to thrive.

How can we scale-up agricultural solutions that are promising? What role do Information and Communication Technologies (ICTs) play in this process? Through a 30-month research initiative, Farm Radio International and Farm Radio Trust (Malawi) aimed to come up with some answers that we explore in this webinar.

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

The term ‘scaling’ is increasingly popular in international development efforts, as it has the connotation of providing a real solution for large numbers of people. However, the popularity of the term is not necessarily matched with a sufficient degree of conceptual clarity, depth of approaches and underpinning of success claims. Good literature and papers on scaling are scarce.

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.

Scaling is still a relatively young area of professional attention, but over the last few years, the international community and development practitioners have taken it up as a priority. With the adoption of the SDGs, aiming for impact at scale has become a broad ambition and expectation. At the same time, the gap between ambition and reality has also become more concrete. Poverty, climate change, and water and food issues need action and solutions at scale. But as there is neither a one-size-fits-all solution nor a silver bullet, scaling runs the risk of taking too easy approaches. Scaling is a complex process, and one that is therefore difficult to realize.

The Scale Up Conference was held September 25-27, 2018, at Purdue University, West Lafayette, Indiana, USA. The conference focused on effective approaches to scaling up agricultural technologies and innovations in the developing world.

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?

Global climate finance institutions aim to spur the transition to low-carbon, climate-resilient economies. The GCF is one such institution and aims to assist the most vulnerable to adapt to and mitigate climate change as part of its mandate to contribute to a paradigm shift towards low-carbon and climate-resilient development pathways. In this paper, we review project documents from 125 GCF investments through March 2020 to examine progress towards these goals. We examine attributes of investments made by the GCF, by applying a framework for transformational change comprising eight components. We use bivariate statistics and multivariate cluster analysis to examine the GCF’s project portfolio of mitigation, cross-cutting and adaptation projects. Bivariate analysis shows that adaptation and cross-cutting projects showed a greater need for and expectation of behaviour change relative to mitigation projects. In addition, adaptation projects showed greater intention to integrate policy change into national planning processes than the other two portfolios but a similar likelihood of catalysing policy change. Multivariate cluster analysis shows that adaptation projects are more likely to be transformational. However, even this likelihood is modest: those GCF investments that show the greatest likelihood of transformational change do not display all eight components under consideration. These findings present learning opportunities for the GCF’s future project selection. The GCF has the opportunity to leverage its current resources to carefully target transformational change more than is currently witnessed. This opportunity is present especially within the Fund’s adaptation portfolio, where its investments address a greater share of global needs compared to mitigation investments.

Seven steps for scaling up The model has seven steps: 1. Develop a plan for new market entry or demand for new crop procurement. The market plan includes clear direction on the commodity needed, the delivery schedule, product specifications, and the cost and quality needed for product manufacture in order to make the business model work for that market. 2. Conduct sourcing survey(s). The agriculture procurement team identifies local sourcing opportunities for existing crops as well as growing parameters, such as climate zone and soil type, needed for crop expansion 3. Identify key players in government agencies, research groups, or consultancy groups. Partnerships with these players help identify current available agricultural capacity and existing local practices that can be leveraged across the grower base. It can deliver close grower relationships, familiarity with target crop(s), relevant research programs, and access to grower capital. 4. Initiate pilot trials. Over two to three growing cycles, agronomists determine the capability of crops to comply with business objectives—answering such questions as yield, quality, cost, and reliability of supply. Global knowledge and experience are brought to bear in the pilots including the use or development of new varieties and agronomic practices. 5. Assess existing infrastructure and needs for the business venture. This includes identification of new capital investment needed for storage, mechanization, or field equipment that will justify support of new improved practices. Agronomists identify new seed programs or varietal replacements necessary to increase yields, better fit local growing conditions, and meet product needs. 6. Continually improve. Agronomists focus on increasing grower yields; productivity and other learnings from pilots and existing practices are shared with growers to develop or refine their expertise. The company develops local resources and invests in research and development that will support the local crop production program. 7. Scale up. The model expands to work with more growers and as the company cycles back with continuous improvement it includes more growers. PepsiCo identifies new supply opportunities and brings these growers into its supply chain, sharing technology and agronomic training so they too can increase yields, productivity, and economic returns while providing the raw material supply needed.

Scaling up food security innovations in low-income rural environments has often failed to achieve substantive and lasting results. This poor performance can be attributed to dominant, linear approaches associated with spreading innovations which entail technology research and development and subsequent transfer to farmers. Such approaches tend to overlook complexity elements and non-linear processes in smallholder agriculture, including multiple stress factors such as climate variability and economic risks that make the uptake of new agricultural innovations more unpredictable. This article presents programmatic lessons from the Canadian International Food Security Research Fund (CIFSRF) on scaling up. It considers projects that: i) deployed successfully pilot-tested innovations to reach and benefit large numbers of beneficiaries; and projects that ii) used innovations as an entry point to catalyse systematic change in the food and agricultural sector. The paper also outlines several key scaling up principles that can encourage better understanding of relevant socio-ecological dynamics and complexities in intervention areas as a way to support innovations (at scale) that can contribute to more sustainable system outcomes. Finally, the paper reflects on how predominant definitions of impact at scale, centered around rather narrow indicators around economic growth and technology transfer, might consider more holistic goals that encompass integrated agricultural interventions that advance sustainable agri-food system outcomes.

There is great untapped potential for farm mechanization to support rural development initiatives in low- and middle-income countries. As technology transfer of large machinery from high-income countries was ineffective during the 1980s and 90s, mechanization options were developed appropriate to resource poor farmers cultivating small and scattered plots. More recently, projects that aim to increase the adoption of farm machinery have tended to target service providers rather than individual farmers. This paper uses the Scaling Scan tool to assess three project case studies designed to scale different Mechanization Service Provider Models (MSPMs) in Mexico, Zimbabwe, and Bangladesh. It provides a useful framework to assess the gap between international lessons learned on scaling captured in forty tactical questions over ten “scaling ingredients” as perceived by stakeholders involved in the projects, as well as private sector actors and government employees. Although at first sight the case studies seem to successfully reach high numbers of end users, the assessment exposes issues around the sustainable and transformative nature of the interventions. These are highly influenced by the design of the projects and by the environment and context of the intervention areas. Across the three case studies, large-scale adoption of the models was found to be hampered by lack of finance to set up MSPMs and insufficient collaboration among the value chain actors to strengthen and foster Mechanization Service Provider (MSP) entrepreneurs. Applying a scaling perspective on each case study project exposed important lessons on minimizing project dependencies. Positive examples include integration of capacity development materials in vocational training centers in Zimbabwe, promotion of MSPMs by other donors in East Africa and levering of nearly USD six million of private sector investment in appropriate machinery in Bangladesh. On the other hand, there is still a high dependency on the projects in terms of coaching of service providers, facilitating collaboration along the value chain, and provision of leadership and advocacy to address issues at governance level. These results have important implications for similar development interventions aimed at increasing smallholder access to mechanization services at scale and is to our knowledge the first cross-continental assessment of these issues to date.

Many studies detail constraints deemed responsible for the limited adoption of new technologies among smallholder farmers in sub-Saharan Africa. By contrast, here we study the conditions that led to the remarkably fast spread of improved chickpea varieties in Ethiopia. Within just seven years, the adoption rate rose from 30 to 80% of the farmers. A combination of factors explains the rapid uptake. Their attraction lay in superior returns and disease resistance. Chickpea was already an important crop for rural households in the studied districts, for both cash income and consumption. Good market access and an easy accessibility of extension services advanced the adoption process. Thus, an attractive technology suitable for rural households in a conducive environment enabled adoption. Our findings prompt us to stress the importance of tailoring agricultural innovations to the realities and demands of rural households, and the need to design and deploy interventions on the basis of ex-ante knowledge on factors potentially determining their success or failure.

Agricultural production involves the scaling of agricultural innovations such as disease-resistant and drought-tolerant maize varieties, zero-tillage techniques, permaculture cultivation practices based on perennial crops and automated milking systems. Scaling agricultural innovations should take into account complex interactions between biophysical, social, economic and institutional factors. Actual methods of scaling are rather empirical and based on the premise of ‘find out what works in one place and do more of the same, in another place’. These methods thus do not sufficiently take into account complex realities beyond the concepts of innovation transfer, dissemination, diffusion and adoption. As a consequence, scaling initiatives often do not produce the desired effect. They may produce undesirable effects in the form of negative spill-overs or unanticipated side effects such as environmental degradation, bad labour conditions of farm workers and loss of control of farming communities over access to genetic resources. Therefore, here, we conceptualise scaling processes as an integral part of a systemic approach to innovation, to anticipate on the possible consequences of scaling efforts. We propose a method that connects the heuristic framework of the multi-level perspective on socio-technical transitions (MLP) to a philosophical ‘modal aspects’ framework, with the objective of elucidating the connectedness between technologies, processes and practices. The resultant framework, the PRactice-Oriented Multi-level perspective on Innovation and Scaling (PROMIS), can inform research and policymakers on the complex dynamics involved in scaling. This is illustrated in relation to three cases in which the framework was applied: scaling agro-ecological practices in Nicaragua, farmer field schools on cocoa cultivation in Cameroon and ‘green rubber’ cultivation in Southwest China.

Finding out how to scale innovations successfully is high on the agendas of researchers, practitioners and policy makers involved in agricultural development. New approaches and methodologies seek to better address related complexities, but none of them include a systematic perspective on the role of capacity in (partnerships for) scaling innovations. We posit that this has left an important topic insufficiently addressed in relation to partnerships for scaling innovations. The need to address this gap became apparent in the context of the CGIAR Roots, Tubers, and Bananas (RTB) Scaling Fund initiative. This paper presents how we explored ways forward in relation to this by combining three methodological approaches: The Five-Capabilities, Scaling Readiness, and the Multi-Level Perspective on socio-technical innovation. This combined approach—dubbed Capacity for Scaling Innovations (C4SI)—was applied in three projects related to scaling innovations for sweet potato, cassava and banana, involving five countries in Africa. It then discusses implications for a partners-in-scaling perspective, the contribution of scaling innovations to sustainable development, the importance of research organisations considering their own capabilities in partnerships for scaling, and the extent to which C4SI was helpful in the three cases—for example, in decision making. The paper concludes that a capacity perspective on the scaling of innovations should be an essential part of a ‘science of scaling’. Finally, it provides recommendations for using the approach or parts of it in research and intervention practice for scaling, pointing in particular to the need for context-specific adaptation.

Capacity development is a major pathway for research for development projects to scale innovations. However, both successful scaling and capacity development are held back by a persistent simplistic focus on ‘reaching more end-users’ and training at the individual level, respectively. This study provides examples of the other levels of capacity development: the organizational, cooperation and enabling environment levels. Drawing on four projects implemented by the International Maize and Wheat Improvement Center (CIMMYT) to scale conservation agriculture practices to smallholder farmers, we discovered that these three other levels are less understood, appreciated and reported on than individual training. Trainings are popular to report on because they are simple to plan, quantify, verify, and budget, and success in most projects is measured by the number of individuals reached and trained. There is little awareness and guidance on how to intentionally design and implement projects to address the other capacity development levels. Using a modified framework with clear examples of various types of capacity development activities, project leaders were able to identify and uncover activities that pertain to each of the four levels of capacity development. We argue that project teams must be aware, able, and empowered to invest in the development of capacities of local organizations and the system they operate in. They must be more explicit about the different levels of capacity development, what they mean in their context, and how to create synergies between them. The framework proposed in this paper can serve as a model for initiatives that aim to identify and address capacities at all four levels in order to contribute to large-scale sustainable change.

Despite a growing body of literature on how to scale innovations to contribute to the Sustainable Development Goals, there has been little attention for how scientists and programme managers engage with the scaling process in practice. Through 36 interviews we found that the dominant understanding of scaling was output and beneficiary-focused, rather than outcome and society focused as the latest literature suggests. This has implications on how scaling is approached in projects on the ground, and on the role of an agricultural Research for Development (R4D) organization such as the International Maize and Wheat Improvement Center (CIMMYT) in bridging science and development. . We recommend more reflection on the scaling process and make more use of scaling capacities and tools to better link scientific knowledge to results on the ground.

We live in an era that calls for large-scale social and environmental transformation. But society has taken only meager steps towards producing the unprecedented changes needed to achieve the Sustainable Development Goals. Those of us working on sustainable rural development understand that we face enormous challenges: from ending hunger and improving nutrition, to preserving vital ecosystems, tackling climate change, empowering women and ending poverty. But we are still caught up in a 20th century paradigm that sees the world as a logical, linear, technology-centric system. This approach has hardly worked in the past, and it will certainly fail in the future. We need to change the underlying system. We need a new way of working. In a new paper, my colleagues and I at the International Maize and Wheat Improvement Center (CIMMYT) joined up with development experts to argue that agricultural development projects should stop focusing narrowly on changing farming conditions within a specific project context. For too long, the dominant approach has been to develop new agricultural practices and technologies, prove that they work, spread them to a few hundred farmers through controlled pilot projects, and then hope this is enough to convince governments, industry and millions of smallholder farmers to do things differently. This is akin to inventing the mobile phone but ignoring the need for electricity, cellular towers, network providers, or any of the other supporting elements that enable the use of the phone. Instead, we argue that projects should be seen as vehicles for changing the underlying system that enables a technology to be successfully used by millions. This means acknowledging and engaging with the complex array of real-world elements that comprise these systems, such as infrastructure, market forces, politics, people and power relationships. We do not suggest that project implementers become experts in all of these things, but rather that they need to take them into account when developing scalable solutions, by studying the best scaling process for a particular context, and positioning their contributions within that wider context. We need to change course and embrace new attitudes, new skills and new ways of collaborating if we want to produce sustainable systems change at scale. And one important part of this process involves reconsidering our approach to pilot programs.

Land degradation threatens the livelihoods and the food and nutrition security of the poorest, most vulnerable smallholder farmers and pastoralists. As a result, migration is accelerating, with an estimated 60 million people in Sub-Saharan Africa at risk of being displaced by desertification and land degradation by 2050.

Imazon, a Brazilian nonprofit promoting sustainable development of the Amazon, exemplifies how social ventures can stay small to achieve large impact. Imazon knew that it could not tackle the enormous challenge of deforestation of the Brazilian Amazon alone. Therefore, Imazon leveraged its “special sauce” – producing trusted, neutral, high-quality data that tracks and reports on deforestation – and made that available to partners that could drive behavior change. After a successful pilot reduced deforestation by 90 percent in two years in the city of Paragominas, Imazon attempted to scale its work across the state of Pará and beyond. Along the way, Imazon learned how to define clear objectives against which to rally stakeholders and measure progress; adapt its work to local contexts; be serial collaborators, while mitigating the inevitable risks of partnering; stay focused on core strengths; and leverage those core strengths to have broader impact. In the end, through open source data, partnerships, and utilizing incentives to drive behavior change, Imazon has contributed to reductions in deforestation and is now applying its learnings to new locations and new issues. This case study is relevant for any social enterprise working to have outsized impact by collaborating with partners to change systems. It is also relevant for any enterprise using data to create incentives for change.
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.

We investigate the impacts of a widely used sanitation intervention, Community-Led Total Sanitation, which was implemented at scale across rural areas of Indonesia with a randomized controlled trial to evaluate its effectiveness. The program resulted in modest increases in toilet construction, decreased community tolerance of open defecation and reduced roundworm infestations in children. However, there was no impact on anemia, height or weight. We find important heterogeneity along three dimensions: (1) poverty—poorer households are limited in their ability to improve sanitation; (2) implementer identity—scale up involves local governments taking over implementation from World Bank contractors yet no sanitation and health benefits accrue in villages with local government implementation; and (3) initial levels of social capital—villages with high initial social capital built toilets whereas the community-led approach was counterproductive in low social capital villages with fewer toilets being built.

Perhaps as many as 2 billion people living in rural areas are adversely affected by open defecation (OD). Those who suffer most from lack of toilets, privacy and hygiene are women, adolescent girls, children and infants. Sanitation and hygiene in rural areas have major potential for enhancing human wellbeing and contributing to the MDGs. Approaches through hardware subsidies to individual households have been ineffective. Community‐Led Total Sanitation (CLTS) is a revolutionary approach in which communities are facilitated to conduct their own appraisal and analysis of open defecation (OD) and take their own action to become ODF (open defecation‐free). In six of the countries where CLTS has been spread – Bangladesh, India, Indonesia, Pakistan, Ethiopia and Kenya – approaches differ organisationally with contrasting combinations of NGOs, projects and governments. Practical elements in strategies for going to scale have included: training and facilitating; starting in favourable conditions; conducting campaigns and encouraging competition; recruiting and committing teams and full‐time facilitators and trainers; organising workshops and cross‐visits; supporting and sponsoring Natural Leaders and community consultants; inspiring and empowering children, youth and schools; making use of the market and promoting access to hardware; verifying and certifying ODF status; and finding and supporting champions at all levels. To spread CLTS well requires continuous learning, adaptation and innovation. It faces challenges. Paradigmatically, it requires major institutional, professional and personal shifts. Opposition at senior levels, pressures to disburse large budgets, demands to go to scale rapidly, and programmes to subsidise hardware for individual rural households, have been and remain threats and obstacles. Issues for review, reflection and research include: diversity, definition and principles; synergies with complementary approaches; scale, speed and quality; creative diversity; and physical, social and policy sustainability. In seeking constructive ways forward, four key themes or thrusts are: methodological development and action learning; creative innovation and critical awareness; learning and action alliances and networks, with fast learning across communities, districts and countries; and seeking to seed self‐spreading or light touch movements. A key to good spread is finding, supporting and multiplying champions, at all levels, and then their vision, commitment and courage.

The use of experimentation by practitioners and resource managers as a policy instrument for effective policy design under complex and dynamic conditions has been well-acknowledged both in theory and practice. For issues such as water resource management, policy experimentation, especially pilot projects, can play an important role in exploring alternate courses of action when faced with long-term uncertainty. While the political aspects of experimentation design and outcomes have been alluded to by several policy scholars, there is lack of empirical evidence that explores their interplay with other factors that may also be critical for scaling up of policy experiments. This paper examines experiences with scaling up of different types of water policy experiments through a Qualitative Comparative Analysis of fifteen pilot initiatives in multiple sectors. Presence of political support is found to be necessary for scaling up in 97 % of the cases studied, followed closely by the need for synergies with ongoing policies and programmes. When in combination with effective pilot planning and strong monitoring and evaluation, both these factors create a sufficient condition for successful scaling up in nearly 60 % of the cases studied.

Household water treatment and safe storage (HWTS) provides a solution, when employed correctly and consistently, for managing water safety at home. However, despite years of promotion by non-governmental organizations (NGOs), governments and others, boiling is the only method to achieve scale. Many HWTS programs have reported strong initial uptake and use that then decreases over time. This study maps out enablers and barriers to sustaining and scaling up HWTS practices. Interviews were carried out with 79 practitioners who had experience with HWTS programs in over 25 countries. A total of 47 enablers and barriers important to sustaining and scaling up HWTS practices were identified. These were grouped into six domains: user guidance on HWTS products; resource availability; standards, certification and regulations; integration and collaboration; user preferences; and market strategies. Collectively, the six domains cover the major aspects of moving products from development to the consumers. It is important that each domain is considered in all programs that aim to sustain and scale-up HWTS practices. Our findings can assist governments, NGOs, and other organizations involved in HWTS to approach programs more effectively and efficiently.

Keywords Household water treatment Enablers Sustainability Scale-up Point-of-use (POU)

As a global nonprofit organization, Evidence Action’s rigorous approach to scaling solutions that improve the lives of millions is apparent in its name and – more importantly – its persistent approach to balancing effectiveness and efficiency. Based on a randomized control trial, prior experience in Kenya, and a successful pilot in Uganda’s Kibuku District, Evidence Action planned to scale the Dispensers for Safe Water program throughout Uganda. When initial efforts did not result in the desired community adoption rates, Evidence Action took a step back.

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.