On September 3, 2020, USAID’s Evidence to Action (E2A) Project and scale-up leader ExpandNet hosted “Synthesis of Scale-Up Lessons.” You can watch a recording of the webinar here:

Thank you to everyone who joined us to learn from experts and implementers who took deliberate steps to increase the impact of effective family planning and reproductive health interventions—to sustainably reach more people and to strengthen policies and programs. Together, we demystified a complex process and shared useful tips that can benefit your project and organization.

Below, our panelists and partners from ExpandNet share responses to the many great questions posed by participants.

Questions and Answers with Scale-Up Experts

Laying the foundation for scale-up

1. What are successful strategies for a mindset shift, what contextual elements need to be in place, and how much time is needed for scale-up? Also, how was “successful scale-up” defined?

Greater dissemination about what works in scale-up is needed to facilitate this mindset shift. Sharing, in the form of webinars, publications, and conference presentations about scale-up experience from large-scale projects that work with a scale-up focus, like E2A, can have influence.

And as you heard, the ExpandNet approach has had significant influence not just on one E2A country activity, but across the whole flagship project. In this way, we hope other large-scale projects that support change in countries will continue to expand the scale-up mindset.

To define scale-up success—one can look at ExpandNet’s definition of scale-up:

“Deliberate efforts to increase the impact of successfully tested interventions so as to benefit more people and to foster policy and program development on a lasting basis.”

Scale-up should expand benefits to greater numbers of people (defined variously as horizontal scale-up, expansion, replication, roll out, etc.) and influence policy and program development—otherwise referred to as institutionalizing interventions in policies, budgets, and operations guidelines (also known as vertical scale-up). Both of these activities are key for scale-up to succeed. “On a lasting basis” is also an important part of the definition, which points to the necessity of focusing on sustainability. Scale-up cannot be considered successful if interventions expanded to new areas are not—or will not—be sustained into the future.

Determining what constitutes success needs to be calibrated against the goals. Some aspects of scale-up success are less frequently measured/captured/quantified, especially those pertaining to institutionalization. Expansion to new areas is more easily measured and documented, as one can count the number of new providers trained, the number of people served, etc. But we have been less systematic in capturing policy change, strengthening pre-service training programs, monitoring budgetary allocations and expenditures, etc.

2. Can we really call “scale-up” a new thing? It has been part and parcel of country and development approaches for 40 years—and before.

You’re very right in the sense that concerns with scale-up are definitely not new, and date back to at least the 1940s when interest in research utilization and, later, the diffusion of innovation science began to blossom. Indeed, publications about experience with scaling up family planning date back to the Matlab experiment in Bangladesh in the 1980s. After the ICDDR,B Matlab field station interventions were deemed successful, the government’s interest in replicating Matlab approaches within the government system were strong, and a process was initiated where the ICDDR,B supported the government to expand the interventions to two districts within the public sector program. However, the need for working more effectively and systematically to achieve scale-up success is more widely recognized these days. Unfortunately not everyone addresses scale-up in a systematic manner.

3. From whom generally comes the desire to scale-up a successful innovation?

It varies. At times, the government seeks to scale-up to address policies they have that are not operationalized. For example, in the late 1970s to early 1980s, the Indonesian family planning program leadership understood the importance of scaling up new interventions and worked closely with the local USAID office to ensure a phased process of national scale-up of successfully tested community-based program innovations.

Other times, the push can be from donors or from technical agencies who have the financial backing of donors when they collectively recognize that scale-up needs to be promoted and funded, following initial piloting of interventions.

4. I noticed Beginning with the end in mind (BWEIM) is decisive for the scaling-up process. At the beginning, who is first responsible for the BWEIM application? Funder? Recipient government? Project implementing team?

Ideally, the government would be totally committed to the idea of beginning projects with scale-up in mind and would be involved in project development from the outset. Iit is immensely helpful when there are local NGOs working on creating government capacity to implement BWEIM approaches on scale-up and who back up federal and state governments in these efforts.

It is equally essential for donors to encourage proposal development and fund projects within a BWEIM framework. If they do, project implementing teams will follow. Government counterparts should be consulted and engaged from the initial discussions of new project proposals. Project implementers have an important role, of course. Ideally government, donors, government and project implementers have the same scale-up mindset.

Moreover, the research community, trainers, or faculty in Schools of Public Health who teach future public health professionals or future researchers need to understand the importance of the BWEIM approach, so it becomes a standard best practice in public health.

5. Can you talk about the process of formative research in informing scale-up? (i.e. often pilots are successful because they are very locally relevant. How do you ensure the new areas for scale-up receive the same attention to diverse local conditions?)

Formative research can play a key role in shaping an intervention that is to be scaled and, for this reason, should be conducted to the extent possible in as representative a way as possible to reflect the varying settings where scale-up is eventually taking place. This way, when you are ready to implement in new areas that differ in significant socio-cultural, economic, or political-administrative ways, information is available to guide implementation in diverse settings. However, understanding what is required for successful implementation in a range of settings cannot be fully accomplished in the initial stage of formative research and, instead, needs to continue to take place through learning and adaptive management during the scale-up process. For example, in E2A’s program in DRC discussed in the webinar, initial testing of the model took place in the post-conflict province of Kivu, where the health system was in a weakened state and health providers less available, forcing the model to look outside of the health system. However, in the scale-up stage, during expansion to three new provinces, where more stable circumstances, government health providers were serving the population already and advocated that they themselves should be strengthened instead. Learning about such adaptation was an important step before considering further institutionalization and expansion.

Partnering with governments

6. National level scale-up requires involvement of public sector actors from the start of any experiment/intervention. Can you share how you are involving public sector actors?

During the webinar, both Dr Oluwayemisi Femi-Pius and Dr Alexis Ntabona addressed how work in Nigeria and the DRC focused on supporting public sector actors with scale-up. For elaborations on these experiences, please refer to publications about the DRC and Nigeria experiences on the E2A website here. The Scale-Up CoP webpage features a webinar where Nigerian colleagues from the public sector Ministry of Health and from Pathfinder International discuss processes and outcomes of involvement of public sector actors. A peer reviewed publication about the DRC experience discusses extensively what Dr. Ntabona presented—highlighting public sector leadership from the outset in conducting an assessment and leading and shaping the direction of the scale-up process. One reliable way to stimulate engagement of public sector actors is to work on interventions that fit within public sector policy and programmatic frameworks and government aspirations. The more government actors see a project helping achieve their goals, the more likely they are to be strongly motivated to collaborate and take leadership of the interventions that we all seek to be scaled.

7. What are the best strategies for building government support when the government has so many competing priorities?

Working within government policy priorities and programmatic frameworks is critical for donors and others who want to be helpful. Involving government counterparts from the initial stages of project design and implementation fosters government ownership of and interest in supporting the activities. As was clear from Dr. Ntabona’s presentation on the DRC experience, involving government officials in the needs assessment and systematically building government ownership of the initiative produced enthusiastic support among leaders who initially stated “projects kill programs.”

8. How does the scale-up resource team navigate settings with decentralized health teams, like in Nigeria, where SMOH’s have a leadership role? I suppose my question is about navigating scale-up resource teams where both federal and state teams have levels of autonomy and authority.

In Nigeria, each state is quite autonomous. Yet, there is an expectation that national policies should be implemented locally. This leads to a complex patchwork of implementation, where some states really “run with” an intervention—like the national task-shifting/task-sharing of family planning services to lower- level cadres—while others lag behind in implementation.

This is precisely where nongovernmental organizations can play an important role as one facilitator of a resource team’s work, helping to coordinate across states and with the national level, for example by setting up learning networks that foster a healthy competition among states. Examples of this include the Challenge Initiative, led by JHU-CCP and the TRAC Platform led by Mid-Space/DOS Center. To be sure, decentralization as enacted in Nigeria and Brazil, for example, presents additional challenges for scale-up that are less common in more centralized setting, and require additional resources to ensure scale-up is proceeding effectively. To read about the role of decentralization in a scale-up effort in Brazil, see this book chapter. And to learn about Mid-Space experience with the states network platform called the TRAC, see this blogpost.

9. What process did you undertake to get buy-in from the Nigerian State Ministry of Health to integrate resource team activities into their routine meetings/activities?

Reports on resource team activities were routinely provided to the State Ministry of Health leadership. The Family Planning Coordinator, who was the vice-chair of the resource team, also engaged with the senior management of the MOH on the need to integrate resource team meetings in routine MOH meetings. The core technical committee (CTC) meeting was identified as a good platform to leverage for integration of resource team activities.

10. Are we doing good enough in defining membership of resource teams, if they don’t have the right level of decision-making power? We may need to do better/more stakeholder and power analysis before forming the resource team.

During the webinar, Dr. Femi-Pius addressed how, before agreeing who should be requested to join the scaling-up resource team in Cross River State (CRS), Nigeria, an extensive stakeholder mapping was conducted in close collaboration with the Ministry of Health. However, it was clear during implementation some non-governmental organizations that should have participated could not be persuaded to join, and others who began from the start did not continue because their funding ended. One of the key principles from ExpandNet guidance is to seek to identify and nurture champions and to engage them early and continuously in ongoing dialogue. Keeping a resource team together to continue advancing the scale-up process over time is not easy, especially when it depends on donor funding. However, donors are increasingly understanding the importance of this work and are supporting it with the needed resources.

11. What are some tips or best practices for continuing to make scale-up progress in settings where turnover is high—like the experience referenced in DRC?

High government staff turnover requires donors to commit to longer funding timeframes. Proposal writers must convince donors of the need for longer-term support when applying for project funding. Proposals need to be persuasive about what scale-up requires, and how it is essential to create a resource team that will have continuity over a sufficient time period to support the scale-up process through the three stages.

A good resource team is one that can survive changes, even when the government changes. Even when key government leaders who are part of the team have moved to new positions, other members of the resource team can keep working and provide necessary continuity. Part of this strategy involves working with levels in the bureaucracy where technocrats are less subject to political change, who can help sustain support despite turnover of key high level champions.

Moreover, building the capacity of local NGOs to support governments with scale-up is critical. An excellent example is the NGO in Nigeria called DOS, whose major purpose is to build the managerial capacity of the government to implement the family planning program.

Another strategy is to focus on vertical scale-up early on, because that commits new leaders to continue the expansion process. Such institutionalization through relevant policy or budgetary changes, new technical guidelines or other regulation can ensure some sustainability of efforts even when turnover of high-level leadership takes place.

Nonetheless, frequent government turnover or changes in leadership constitute a critical problem for scale-up, because such turnover is a very common occurrence, and scale-up takes time.

12. What is the private sector contribution? Any experiences to share?

Some experiences with the private sector show it can play a very important role in serving people’s needs, but given that the private-sector also has a profit-motivation, efforts must be made to ensure a sound business model that addresses their interests is built into the scale-up process. For example, in Uttar Pradesh, India, the Urban Health Initiative made efforts to link the private and public sectors, helping to build a strong relationship which strengthened availability of a range of contraceptive methods across the state. Conversely, in Nigeria, the two sectors work more in isolation and, as such, coordinating among them is a greater challenge. Experience has shown that when professional associations can be brought in as part of a scale-up process—to help coordinate among an otherwise decentralized private sector—productive outcomes can be achieved.

Learning and adapting

13. There is a tension between scale-up a predefined approach, and the continual need to update knowledge and skills to address needs as they evolve and become better understood (and as program evidence evolves). Can panelists please comment on good practice for ensuring approaches are up to date while aiming for scale and coverage?

Adaptive management of scale-up focuses on learning and adapting during the implementation process. A variety of resources can be found on the internet to support this process. ExpandNet has a new tool that can assist with adaptive management and documentation of scale up, called the Implementation Mapping Tool, which can be requested by writing to expandnet@expandnet.net. It will also be on the ExpandNet website soon.

14. What are the two most important things to document about scale-up processes, for replication as well as for learning?

1. Successes as well as challenges with use of systematic approaches to scale-up need to be further documented, so there are readily available examples from which everyone can learn lessons from experience with how the three stages of scale-up.

2. Learning from failures is also important, so the costs of failures are clear, and the lessons can be documented.

15. I’m always a bit wary of the phrase: Don’t reinvent the wheel. Complexity means that we are always reinventing—we have to always reinvent—the wheel. Of course you need to mine past experience for lessons that can be applied to the new situation, but you really need to focus on the distinctiveness of the new situation.

You are right; we must both reinvent and learn from past experiences. Mining past experiences includes building on approaches and frameworks and considering them best practices rather than seeking to continually create new ones. Although each new setting or context is unique, there is a body of learning that can be applied to inform the necessary adaptations to the context for successful implementation.

Cost and other challenges

16. Have you estimated the cost of scaling up some health interventions, especially family planning? Also, what are some challenges projects have encountered when trying to scale up?

In the past, there has been substantial work done to determine the costs of family planning interventions and programs, when implemented in certain areas or at full scale. This has continued more recently with the extensive work on developing national and local level “Costed-Implementation Plans.” However, a focus on the costs—during the process of scale-up is much less common. Now projects are increasingly focusing on the need for and using costing data for scale-up. The Maternal and Child Survival Program (MCSP) is one project that gained much learning on how to generate and use costing data to help guide scale-up processes in countries. For an example, see this publication.

More generally, it is important to recognize that if one starts with a scaling-up mindset then unnecessary and non-replicable costs of interventions that do not fit existing systems are kept to a minimum. Still, scale-up is not the same as routine program implementation and does require specially dedicated resources until interventions are fully institutionalized. One of the challenges is that this requires support for the phase of managing the scale-up process, as was mentioned during the webinar.

17. Sustainable scale-up of new “ technical innovations”—namely health products and devices (e.g HPV testing for cervical cancer screening, self-injectable contraception)—requires a budget commitment from countries and government coordinated procurement of these supplies. This is often more challenging than changing clinical guidelines. Can you describe specific strategies used to get these items included in national budgets?

Key to ensuring a budget commitment for new technologies is seeking opportunities to anchor components of the intervention package you are scaling within large-scale activities already underway in the country. For example, during the webinar, Dr. Femi-Pius spoke about how family planning was a component of the larger Government of Nigeria initiative entitled “Saving One Million Lives.” Cross River State was able to mobilize funding from this opportunity to support costs of family planning service strengthening interventions and for supplies.

Sometimes, involving other donors can be a key step. Undertaking environmental scanning for new windows of opportunities (and threats) is a key scale-up activity. Referring back to ExpandNet’s 3-stage process, having government leadership from the outset of Phase 1—namely piloting/local testing with scale-up in mind—will help ensure that needed supplies, for example, will be part of the solution process, and help ensure that funding is allocated in the budget.

18. Often projects are not funded for capacity building—is there any advice on how to address this? E.g. advocacy, follow on funding etc…?

Even though a project has no explicit capacity-building funding, you can build opportunities for capacity building into ongoing activities. For example, field visits to projects or other forms of project review can provide opportunities to share experiences or engage in discussions that amount to capacity building. In addition, follow-on funding is worth pursuing, and it’s important to be creative and integrate what is de facto capacity building into other activities, if an explicit focus on capacity building is not part of formal project objectives.

19. I really appreciate the realistic experiences presented about the need of systematic scale-up that require small and consistent steps to ensure sustainable change. Today, it seems the idea of small incremental changes is no longer popular. More and more, donors want “big change” quickly and encourage the “fail fast and fail big” attitudes. How to balance what we know works about scale-up (i.e. small systematic changes for sustainable scale-up) with the need to adapt to changing donor needs and priorities?

ExpandNet defines scale-up as taking “deliberate efforts to increase the impact of successfully tested interventions so as to benefit more people and to foster policy and program development on a lasting basis.” That is typically asking for very substantial change, while requiring that the process be conducted in a systematic way so that success is feasible.

It is normal for donors and governments to wish for rapidly expanding interventions that appear to be successful. But experience has shown that such “explosive” scale-up can result in interventions that lose their intended impact and/or are not sustained. Particularly early in expansion, small steps are essential to allow for learning required to make large-scale success feasible. For example, as expansion of successfully tested interventions moves to new and different socio-cultural and institutional contexts, it is essential to learn how the package and approach need to be adapted to this context, while maintaining components essential for success. Thus, there are times when seemingly small steps are needed (e.g pausing to assess how the package needs to be adapted) in order to achieve large-scale success.

We need to be clear that “fail fast and fail big” does not benefit the people who need public health interventions and also represents a waste of scarce resources. We believe systematic scale-up is the best way forward.

LEARN MORE
Explore systematic scale-up at E2A.