Phase IV: Going to Scale with Successful Change Efforts

Scaling up brings new responsibilities to the coordination team, which might expand to include representatives from new locations and institutions. The team shares the findings from the pilot test to a larger audience and works with decision makers to select, carry out and evaluate an appropriate implementation strategy. An influential coordination team can ensure sustainability by assisting governments in mainstreaming new practices into policies, systems and programs. In addition, the team oversees the careful and honest mea­suring and widespread communication of the results of the scaled-up practice(s).

Step 1. Evaluate, consolidate and disseminate lessons learned from the pilot, and decide whether the practice warrants scale up.

The results of the pilot will inform the decision of whether to scale up and will lend credibility to the practice.

Challenges

  • Evaluating the results of the change effort systematically, honestly and objectively so that plans for scaling up are realistic.
  • Shaping messages that will convince selected audiences to support the new practice(s).
  • Knowing and using the most effective communications channels for each audience.
  • Having sufficient information to assess whether the capacity exists to implement the change in routine program settings.
  • Feeling pressure to scale up the change, even in the absence of conclusive results.

Note: Some change efforts fail and are not appropriate for scale-up. In such a case, the coordination team should objectively analyze the reasons for failure and share the findings with stakeholders. An effective team can encourage the organization to learn from the failure and try again.

Underlying causes of the challenges

  • Coordination team members and change agents who have invested time, energy and their professional reputations in the change effort might be tempted to exaggerate positive results and overlook less successful aspects of the change effort.
  • Members of the implementing team might lack expertise in effective communi­cation strategies.
  • The pressure to move ahead with scale-up can be strong because the change addresses a perceived need. 

Key activities to address the challenges

  • Evaluate and document lessons learned, results and adaptations for different audiences.
  • Share the documented process and benefits with stakeholders to engage them in identifying resources for scaling up.
  • Acknowledge that ignoring negative factors will result in unrealistic plans for scale-up with a higher likelihood of failure.
  • Share with decision makers the benefits of a systematic review of the chances of success in order to avoid a premature decision on whether to scale up the practice.
  • Use both personal (for example, peer exchanges) and impersonal (for example, reports and websites) means of dissemination.

Step 2. If the pilot succeeded, use a systematic approach and participatory process involving key stakeholders to develop a scaling-up strategy and secure resources to support implementation of the strategy.

The coordination team must advocate effectively for scale-up with new organizations and players. This will be facilitated if some members of the new organizations have been involved in the demonstration process and advocacy for scale-up was initiated early on. Scale-up should be approached systematically and should be technically and financially feasible. Capacity building for scale-up will enhance ownership, cultivate champions and provide opportunities to mobilize resources to institute change on a larger scale.

Challenges

  • Mobilizing the needed resources for scale up.
  • Simplifying the implementation package to lend itself to expansion.
  • Building capacity to expand implementation of the change package.

Underlying causes of the challenges

  • Not all stakeholders might agree on the wider applicability of the new practice(s).
  • Few are prepared to support implementation of a systematic approach to scale up.   
  • The coordination team might lack the information needed for an accurate estimate of needed resources.
  • Resources for scale up are limited.
  • The organizations newly adopting the change might lack certain necessary capacities.

Key activities to address the challenges

  • Apply an evidence-based scale-up framework or model to the strategy development process.
  • Identify and mobilize stakeholders with experience in scaling up change to support the development of an appropriate scaling up strategy.
  • Plan actions to increase the scalability of the change.
  • Strengthen the capacity of the implementing organizations to scale up the change.
  • Assess the environment and identify actions to increase the potential for scaling up success.
  • Build the capacity of the implementing team to support scaling up.
  • Make strategic choices to support institutionalization, expansion or replication in other sites.
  • Determine whether adaptation of the innovation is needed for new contexts.
  • Plan to address spontaneous scale-up in case it occurs.
  • Prepare and circulate a written statement that documents the scaling up strategy, the time frame and who is responsible for key activities.
  • Become familiar with and weigh the requirements, risks, advantages and disadvantages of different approaches to scaling up.
  • Be cautious making plans and commitments for overly rapid scale up.
  • Mobilize resources from a variety of donors.
  • Look for economies of scale and partner with other change efforts where possible and efficient.

Step 3. Monitor the process of scaling up to ensure sustainability and provide evidence-based decision making.

Monitor implementation of the practice to understand both the benefits and shortcomings of the practice in order to adapt practices midstream and address challenges.

Challenges

  • The need or desire to move quickly and not take the time to measure progress and results.
  • Integrating systematic M&E, which is typically already a weak area, into the change effort without overburdening the change agents or system.
  • Finding relevant indicators that accurately capture the key elements of the change.
  • Data might be of poor quality (incomplete, inaccurate, confusing), too difficult to obtain or reported inconsistently.
  • Gathering information on the process of implementation, not just on the outcomes, outputs and impacts.

Underlying causes of the challenges

  • The coordination team members might not appreciate the value of monitoring progress in order to make mid-course corrections and avoid failures down the road.
  • The M&E plan might be too long or complex and might not be capitalizing on existing systems and reporting practices.
  • The M&E plan does not define what information should be collected for each indicator, from which data sources, by whom and how frequently.
  • The selected indicators might not reflect all the anticipated results, both quantitatively and qualitatively.
  • Implementing teams might not be accustomed to collecting process data and information.

Key activities to address the challenges

  • Ensure that monitoring activities are built into the implementation plan or work plan (including the budget) and adhere to the predetermined monitoring schedule.
  • Keep the M&E plan simple and, to the extent possible, linked to existing reporting structures, systems, processes and practices.
  • Add relevant indicators to standard data collection instruments.
  • Establish sentinel surveillance sites between major surveys.
  • Seek social indicators from organizations that provide and assess social services.
  • If necessary, revise the indicators so that they are clearly defined, useful, not redundant and not trying to capture information that is too difficult to obtain.
  • Create a reference sheet for each indicator specifying what information is needed, how the indicator is calculated (if relevant), what the sources are for required data, who will be responsible for collecting the data and how often data will be collected.
  • Establish mechanisms through which change agents and their teams can learn from each other.
  • Use both qualitative and quantitative approaches to monitoring including service statistics, where available, as well as special studies.
  • Looking at the monitoring data, assess whether the core elements of the innovative change practice are being maintained.
  • Assess results and outcomes of large scale implementation, including any unanticipated results.
  • Recognize inadequacies of management information systems, agree on an acceptable level of accuracy and timeliness and remedy deficiencies that can be rapidly improved.

Step 4. Implement the scaling-up strategy. 

In this step, the practice is mainstreamed according to the implementation plan, fostering sustained improvement.

Challenges

  • Lack of resources to support large-scale implementation or difficulty maximizing existing resources to gain the most benefit for scale-up.
  • The need for a change coordination team will not be apparent to all stakeholders.
  • If the innovation is complex or requires new systems, structures, technology or patterns of behavior in the implementing organization, time and possibly considerable funding and training and support might be needed.
  • Preserving the critical features of the new practice as it is expanded and extended.
  • If institutionalization requires working within existing rhythms of policy change, progress can be slow. Maintaining momentum and enthusiasm can be especially difficult over the long process of national scale up.

Underlying causes of the challenges

  • Health managers often feel pressure from donors or political leaders to start whole new initiatives, which diverts attention and resources away from scaling up ongoing practices that do not have new funding. Many stakeholders consider scaling up to be part of routine program implementation and fail to recognize that the change requires nurturing and buy-in at expansion sites.
  • Implementers can become frustrated by the time, persistence and energy needed to car­ry out a complex, multifaceted scale-up effort and often prefer to work on new initiatives.
  • New practices can become diluted and lose their impact as they spread to new settings.

Key activities to address the challenges

  • Ensure the continued presence of a strong, motivated change coordination team.
  • Ensure that additional change agents and implementing teams are established in new sites so that scaling up receives the needed support at the local level.
  • Conduct training and other supportive activities to ensure that the innovative change practice is well understood at all levels.
  • Ensure that the practice is adapted to the local context while maintaining fidelity to its key components.
  • Establish and adhere to criteria to maintain the essential features of the practice(s).
  • Advocate for necessary policy and related institutional change.
  • Adjust the scaling up strategy based on lessons learned from experience and M&E.
  • Partner with other relevant change efforts.
  • Review the indicators that were selected for the demonstration and determine whether they are all still appropriate for the scale-up.
  • Monitor the process to identify barriers to scale-up.
  • Mobilize resources that support the costs of scaling up, including continued support of the change coordination team.
  • Recognize and reinforce the new practices and discourage outdated ones.
  • Identify new change agents in the sites where the innovation is expanded.
  • Systematically maintain incentives, public recognition and rewards for implementing teams.

Step 5. Evaluate and communicate the progress of the scale-up to key stakeholders.

Evaluate the monitoring data and use the information to make decisions. Communicate the findings from monitoring activities to key stakeholders and collaboratively plan for future iterations.

Challenges

  • Reporting on the indicators but not analyzing the data to identify areas where the change process might be faltering or need extra attention.
  • Communicating key information to decision makers in a constructive and timely manner.
  • Giving honest feedback when performance falters.
  • Dedicating time for thorough, objective evaluation.

Underlying causes of the challenges

  • There is not a strong culture of data use and making decisions on evidence-based findings.
  • Coordination team members and the change agent might be unfamiliar with the use of indicators to objectively evaluate performance or unaccustomed to giving constructive feedback.
  • It is often uncomfortable and even difficult to communicate negative results, particularly to superiors or donors.

Key activities to address the challenges

  • Encourage the coordination team members to provide evidence from the M&E plan for their recommendations and decisions. If needed, provide tools and resources on how to use data for optimal success.
  • At the start of scale-up, establish a principle of transparent and honest reporting, and make a plan for communicating negative results.
  • Present results to those who are implementing the change (service providers, policy makers, community leaders) as well as national and international audiences.
  • Find or develop written guidelines for effective, constructive feedback.
  • Hold a brief training session to discuss the guidelines and ways to develop and use indicators.
  • Acknowledge the difficulties staff might encounter, and be prepared to make practical suggestions for improvement.

Resources