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.

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.