Step 7: Scaleup for National Impact and Sustainability

Scaling up capacity building, community outreach and demand generation for maternal and newborn health interventions is critical for sustaining program improvements. However, as country programs are selecting strategies and interventions to scale up AMTSL, they encounter large-scale challenges, such as inadequate providers’ skills, low community awareness of danger signs and need for referral, and facilities without evidence-based protocols and medications.

Develop a scale up plan considering national priorities, areas of highest need and capacity: Depending on the national strategy, expansion of PPH initiatives may be phased but should be developed with a long-term vision of routine delivery of these services through existing government systems nationwide. Issues to consider and address in the plan include: logistics; product registration; training; funding; M&E (HMIS); behavior change communication; QOC; and capacity-building.

Plan for integration into other programs/services where feasible: Often PPH prevention and management interventions start as pilots, but once successfully demonstrated, scale up is challenged to shift from a vertical project to integrated activities within the broader maternal and newborn health national program. Integration makes sense when it’s synergistic—mutually strengthening and reducing needed resources (such as human, financial and time).

Consider the role of the private sector, including social marketing: PPH expansion should consider how to achieve the greatest coverage, which may include involving the private sector and social marketing/franchising.

Incorporate issues to promote sustainability: Sustainability can be built into the initial program design using the framework and tools. New innovations in particular need to consider sustainability in the initial design and implementation.

Program Pitfalls and Lessons Learned: Expansion & Sustainability

 When ownership of MNH services comes from the grassroots level, creating demand and supply, the health system and policy environment are more flexible to support decentralized implementation of the new interventions.

 A modern approach to training in basic EmONC competencies—with a greater focus on skill development—will increase provider confidence and capacity to adopt new practices.

 Maternal/newborn health interventions, and specifically BEmONC services, need more focused advocacy with key decision makers.

 In many countries with a human resources crisis, addressing improvements systematically is a challenge. Plans should be in place for community-based activities, including task sharing when appropriate, in order to “decongest” maternity hospitals.

 Quality and performance improvement approaches, such as SBM-R, should focus an intensified effort on prevention and management of PPH as an essential element of quality care.