ExpandNet & WHO Tools for Fostering Change for Scale-up

ExpandNet, in collaboration with the World Health Organization (WHO)/Department of Reproductive Health and Research, has combined comprehensive literature reviews, extensive field experience and a conceptual framework to produce several guidance tools that support policy makers, program managers and those providing technical assistance with strategic planning and management of the scaling-up process. These tools, outlined below, were developed to ensure that the benefits of proven health practices are sustainably expanded and institutionalized to benefit more people.

Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up.

Pilot projects often show impressive results, but their influence tends to remain confined to the original target areas, and their results are often unsustainable. One reason for this is that the requirements of large-scale implementation are rarely taken into account at the time of pilot or field-testing. The beginning-with-the-end-in-mind guide provides 12 recommendations and a checklist to help build scaling up considerations into projects from the earliest stages of designing a pilot, demonstration or other operations research intervention. The recommendations, which stem from peer-reviewed literature, as well as experience, are as follows:

  1. Engage in a participatory process involving key stakeholders.
  2. Ensure the relevance of the proposed innovation.
  3. Reach consensus on expectations for scale-up.
  4. Tailor the innovation to the socio-cultural and institutional settings.
  5. Keep the innovation as simple as possible.
  6. Test the innovation in the variety of socio-cultural and institutional settings where it will be scaled up.
  7. Test the innovation under the routine operating conditions and existing resource constraints of the health system.
  8. Develop plans to assess and document the process of implementation.
  9. Advocate with donors and other sources of funding for financial support beyond the pilot stage.
  10. Prepare to advocate for necessary changes in policies, regulations and other health systems components.
  11. Develop plans for how to promote learning and disseminate information.
  12. Plan on being cautious about initiating scale-up before the required evidence is available.

Nine steps for developing a scaling-up strategy.

Once testing is complete, strategic planning for expansion and institutionalization of successful health innovations should happen. However, while there is often interest among program managers and others in engaging in a systematic planning process, these players often lack the experience, know-how and resources to do so. The tool Nine Steps for Developing a Scaling-up Strategy can enhance capacity among managers and others to complete these tasks.

The nine-step guide assists program managers, technical assistance personnel, researchers and policy makers with the process of developing a scaling-up strategy. This document has been used in a facilitated process of strategy development with program/project managers from a range of countries including Guatemala, India, Kenya, Kyrgyzstan, Madagascar, Mali, Peru, Rwanda, Senegal, Sierra Leone and Yunnan, China.

The ExpandNet framework for scaling up is a roadmap that guides step-by-step development of a scaling up strategy. The framework consists of five elements:

  1. The innovation: this is not just a new technology or practice but also the supportive factors (counseling, supervision, logistics) required for implementation.
  2. The user organization which is expected to implement the innovation (Ministry of Health, NGO, private org, or a combination of these).
  3. The environment: the larger context within which scaling up takes place.
  4. The resource team which supports the process.
  5. The scaling up strategy: the means by which the innovation is communicated, disseminated or otherwise promoted.

Two types of guided scaling up are expansion and institutionalization. Expansion refers to the implementation of the cnage practice in different geographic sites or service facilities, or to its replication with larger or different population groups. Institutionalization refers to the policy, political, legal, regulatory, budgetary or other changes needed to ensure the practice is incorporated into the health system on a sustainable basis. The strategy development process must address questions about each element of the framework and determine what actions must be taken for successful scaling up.

Practical guidance for scaling up health service innovations

This document provides a more comprehensive examination of scaling up than the Nine-Step Guide, focusing not only on how to scale up innovations but also how to strategically plan and manage scaling up. It was developed in response to the need expressed by program managers, policy makers and technical assistance personnel for practical guidance to assist with the process of scaling up.

Who should use these tools, and when?

Beginning with the end in mind is intended to help those who design pilot projects or other programmatic research increase the likelihood that the practice can be implemented on a large scale if proven successful. The tool can be used in the initial stages of a project and throughout the process to make necessary adjustments.

Nine steps for developing a scale-up strategy is for those who have successfully field-tested an innovation and are ready to scale it up. The guide and key questions from the accompanying worksheets help facilitate the development of a scaling up strategy. ExpandNet members have used these tools to facilitate participatory planning processes in several countries in Asia, Africa and Latin America.

The Practical Guide is relevant throughout the entire scaling up process, from pilot development and implementation to the management of scaling up. It provides insight and lessons learned from global experience with scaling up.

Using the tools in a participatory process

The nine step guide leads users through an analysis of their project that results in a set of recommendations for action which will form the basis of a strategy to scale up successful pilot or demonstration project. The guide is accompanied by a set of worksheets with detailed questions that support the process of strategy development. These two tools can be used by individuals, a small team or in a multi-stakeholder endeavor. The essence of the strategy development process involves asking a set of questions about each of the elements of the framework and determining what actions need to be taken to increase the potential for successful scaling up.

Members of ExpandNet and the WHO Department of Reproductive Health and Research have used the ExpandNet framework and tools in a participatory, country-led process that is grounded in field realities. Country strategy development exercises have typically involved the following six components; however, the details have differed depending on the country situation.

  1. Exchange of materials and other preparatory steps between ExpandNet facilitators and the project team, which can include local translation of guidance materials.
  2. Initial meetings with the project team after arrival in-country to allow in-depth discussion of the current status of the project is discussed and orientation to the ExpandNet framework and nine-step approach.
  3. Field visits and stakeholder interviews. Facilitators and country team members visit project sites and non-project sites to understand the local context and perspectives. Discussions with providers, program managers, community members and clients provide opportunities to understand how the project is implemented on the ground and to identify challenges and opportunities for scaling up.
  4. Workshop preparation. After field work, the project team and facilitators decide which questions from the strategy development worksheets should be answered during the participatory stakeholder workshop.
  5. Two-day strategy development workshop. Workshop participants are key stakeholders in the scaling up process who together analyze the innovation; the implementing organization(s); the resource team who will support the scaling-up process; and the socio-economic, cultural, political and bureaucratic environment in which scaling up will take place. Action steps needed to scale the innovation up are identified and recorded and, taken together, constitute the building blocks of the scaling-up strategy.
  6. Follow-up. After the workshop, the project team revises workshop recommendations and assembles them into a scaling-up strategy document, which is presented to relevant stakeholders and task forces.

Examples of outcomes from using ExpandNet/WHO tools

Using Beginning with the end in mind: The HoPE-LVB Project team, comprised of conservation and reproductive health NGOs working together on a population health and environment project in East Africa had been planning to themselves undertake capacity-building activities in sustainable agro-forestry practices at the community level. When they reoriented their thinking towards strengthening sustainability and scalability or project interventions, they opted instead to mobilize existing structures such as the inactive village environmental committees, subcounty council members working on the environment and district-level environmental officers, thereby embedding the knowledge and training capacity more deeply and widely than in just the community where the project is working.

Applying the nine-step strategy development approach: The UNFPA-led Stronger Voices project in Kyrgyzstan, which sought to strengthen both demand for and supply of quality SRH services, was scaling up from a few initial pilot villages on the basis of intensive village-level training by national level Ministry representatives. This approach was not sustainable and was unlikely to yield large-scale impact. As a result of the scaling up strategy development workshop, plans were made to link the project with national health reform and financing mechanisms already underway, to join forces with related community interventions funded by other donors and, perhaps most importantly, to shift from a village-by-village approach to a district-wide focus that newly involved local government authorities.