Scaling up health interventions: What works? isn’t the most important question

Scale-up efforts aim to extend new services and practices to all health services so that they reach the people who need them, during the project and into the future.

Scale-up efforts aim to extend new services and practices to all health services so that they reach the people who need them, during the project and into the future.

I spent most of 2014 working with American colleagues to derive lessons about scaling up high impact maternal and child health interventions in developing countries. Getting an innovation—a new drug, clinical practice or program—to more people and making it a lasting part of the government health system is the goal of many ministries of health and international aid donors.

The project was based on the experience of the USAID funded Maternal and Child Health Integrated Program (MCHIP) which has increased access to health promoting and life-saving interventions in over 50 countries between 2008 and 2014. A program of this size offers a unique opportunity for learning what strategies work to scale up health interventions.

Over the next few months I will post some of the project findings and my evolving thinking about how global programs—or indeed any program—can improve health by introducing, expanding and evolving new practices.

The project on MCHIP’s experience of scaling for impact started with a review of 18 cases selected by MCHIP technical teams. To make sure results were generalizable across intervention, the 18 cases were taken from six technical program areas: new vaccine introduction; prevention of post-partum haemorrhage; newborn resuscitation; post-partum family planning; preventive treatment of malaria for pregnant women; and, community-based case management of common childhood illnesses. All of the cases aimed to spread the intervention nationally and to make it a part of the routine business of the government health system.

Outcome variables were changes in the coverage of the intervention (expansion to new geographic areas or facilities and increased utilization rates) and self-rated measures of institutionalization completed by in-country teams.

Our study only looked at scale-up efforts and outcomes over a relative short period, usually two to four years. In that time, the cases of introducing new childhood vaccines were very successful, achieving at least 80 percent coverage in the first year. Some cases were making excellent progress towards their goals while others had yet to see any improvements in coverage although the intervention had become an official part of the national health system.

The introduction of new vaccines obviously benefited from strong national immunization programs that were able to plan and account for rapid national expansion. But there were some factors that distinguished the other cases which did and did not take the intervention to scale.

Virtually all of the cases investigated had these elements:

  • Advocacy to win in-country support for scaling up the intervention
  • Government ownership of the scale-up process, at a minimum through a high level technical committee
  • Development and endorsement of policies and guidelines to describe the intervention and how it should be implemented
  • Cascade training to teach all or most health workers about the new practices.

 

But there were some strategies that were only employed in a few case studies:

  • Involvement of sub-national officers and facility managers in promoting and monitoring implementation
  • Use of routinely collected performance data to monitor progress and adjust the scale-up process when necessary
  • Reinforcing the new practice through mentoring, intensive supervision or other strategies to make it easier for frontline workers to adopt the new practices

The scale-up cases using the second set of strategies tended to be more successful. Those that did not still achieved their targets for the number of districts to be covered and the number of health workers trained but did not appreciably increase the number of people who received the life-saving services.

The full report of this work can be found on the MCHIP website here.

But recommendations to design better scale-up plans are not likely to lead to better scale-up plans. Similar recommendations have appeared in many guidelines and articles over the last twenty years. For example, a nine-step guide produced by ExpandNet, a global network of public health professionals and scientists dedicated to scaling-up high impact health interventions.

When we talked to key informants about implementing the scale-up efforts, they were aware that focusing on policy development and training alone was insufficient. They explained that it was necessary because of funding restrictions or were concerned that more intensive strategies (such as extra supervision or parallel record keeping) were unsustainable. Others pointed to resistance from key stakeholders or major external shocks as the reason the intervention was not yet reaching the people who needed it.

In the second phase of the project we took a different approach. We were still interested in which scale-up strategies were effective, but we were more interested in understanding how specific strategies worked in specific settings with the obstacles described by our key informants.

… that meant the context was as important as the intervention and the scale-up effort to understanding what worked.

… and that realization led us to pay much more attention to what health systems are. It turns out they are complex. Scaling-up efforts have to work with rather than against that complexity if they are to be successful.

 

Acknowledgements

I was contracted through John Snow Inc for this project and worked closely with JSI staff Jessica Posner, Anne LaFond and Natasha Kanagat. Dr Jim Ricca, Senior Learning Advisor for MCHIP guided the work.

In India I loved working with resourceful team from iMaCS lead by Dr Rajesh Khanna and Prakash Philip. In Mali I would have been lost without the support of Dr Mamadou Kani Konaté and his team at Marikani.

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