Promoting Scale-Up Across a Global Project Platform: Lessons from the Evidence to Action Project

Abstract

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.

Tensions and Paradoxes of Scaling Up: A Critical Reflection on Physical Activity Promotion

“…Systematic reviews have identified barriers to scaling-up public health programs including: a lack of policy/political support, lack of funding and other resources (e.g., human and infrastructure) for scaling-up and a perceived lack of need for the proposed intervention [ 7 ]. Whilst there are some successful scale-up examples in public health (e.g., reproductive health [ 8 ] and HIV testing [ 9 ]), for complex non-communicable disease risk factors, such as physical activity [ 10 ], few research-led interventions have achieved sustainable delivery and impact at scale [ 6 ]. Globally, this remains problematic; despite significant investment by governments internationally, physical inactivity levels remain high [ 11 ], contributing to healthcare costs in excess of INT$50 billion [ 12 ].…”

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

“…In particular, vertical scale-up – the institutionalization of a public health intervention in the national health system – is complex, as it is a non-linear process, involves a variety of stakeholders and takes place in complex health systems [ 5 ]. Because of the limited understanding of how to deal with this complexity, only a few successfully tested interventions are scaled up and become part of national systems [ 5 , 6 ].…”

“…This has led to more tangible experiences with scale-up practice, research and critical reflection, which has contributed to a ‘new understanding’ of good practices around scale-up. For example, policymakers and implementers increasingly consider and reflect on how to scale up from the beginning of implementation of an intervention, instead of scale-up being an ‘afterthought’ [ 6 , 8 ]. Other notable changes in approaching scale-up are considering the political economy during scale-up and taking a holistic systems approach.…”

“…There are tools and guidelines available that have emerged based on this improved understanding [ 7 ]. However, as Ghiron, Ramirez-Ferrero [ 6 ] recently stated, “there has been little documentation of how large multi-country, donor-funded projects have sought to address the importance of scale-up in the design and implementation of their initiatives”. The aim of this study is to address this knowledge gap and to provide insight in which factors and processes, from now onwards called “facilitators”, positively facilitated the scale-up of a specific health intervention – the district-level health management strengthening intervention – in contexts which are shaped by different systemic and general contextual factors.…”

Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review

“…Implementation science (IS) is the study of methods to promote the systematic uptake of research findings and other evidence-based practices (EBP) 1 into routine practice ( 8 ) in order to improve the coverage, quality, sustainability, and effectiveness of health services ( 9 ). Although embedding research in FP programs is not new to LMIC ( 10 ), applying IS as a formal discipline in global health initiatives is nascent, and can contribute to large-scale successes needed to achieve universal healthcare coverage (UHC) and the Sustainability Development Goals (SDGs) ( 11 – 14 ). Recognition of this potential illuminates a gap in understanding how well and widely IS is employed and how its principles, concepts and methods could be applied to increase impact of FP programs in LMIC ( 15 , 16 ).…”