How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda

Abstract

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.

Strengthening district health management and planning: an evaluation of a multi-country initiative in Eastern and Southern Africa

“…These included availability and timeliness of funding; simplicity and coherence of planning templates and guidelines; quality of health information systems; staff turnover and staffing levels; partner alignment; emergencies; decentralization arrangements; political structures; and the influence of other initiatives and systems designed to support effective management. Many of these factors have been identified in other research on efforts to strengthen district planning and management, including aspects such as uncertain resourcing, decentralization and decision space, staff turnover, high workloads, and a supportive working environment 7,37,[44][45][46] . The 2007 WHO Framework for Strengthening Health Leadership and Management also highlights the need for not just appropriate competencies, but also an adequate number of managers, functional support systems, and enabling working environments 47 .…”