Search results
An initial review of abstracts in electronic databases against the inclusion criteria yielded 100 abstracts, and searches of the grey literature further identified four documents. Of the 104 papers and documents reviewed against the inclusion criteria, 29 papers recommended effective interventions for scaling up, but did not examine concepts, theories and models in any great detail (so were excluded), 11 papers provided accounts of scaling up processes of public health interventions and 25 papers described concepts, theories and models relevant to scaling up public health interventions. The majority of papers excluded from phase 1 of the review (n = 41) focused on health service interventions, particularly expanding anti-retroviral treatment for HIV in low income countries.
In phase 2 of the review, a total of 38 full papers and reports were retrieved and reviewed against the inclusion criteria (n = 38), with 11 papers providing accounts of scaling up processes of public health interventions. Twenty-five papers and reports described concepts, theories and models relevant to scaling up public health interventions, of which 24 were included in the final review.
Additional file
1: Table S1 summarises characteristics of papers and reports focusing on concepts, theories and models relevant to scaling up public health interventions including reference details, study type, concepts, theories used or proposed, key concepts, elements of the model or framework, context and success factors and important findings. A number of studies were both case studies and proposed theoretical frameworks for scaling up public health interventions and were described as such in the ‘study type’ column of Additional file
1: Table S1.
Frameworks for scaling up public health interventions
The review identified eight frameworks [
7,
9,
23‐
28] (see Table
2), the majority of which had an explicit focus on scaling up health action in low- and middle-income countries, indicating a gap in scaling up methods in high-income country contexts. Of these, three frameworks focused on scaling up specific health interventions [
23,
27,
28] (i.e. insecticide-treated nets for malaria, promoting breastfeeding and maternal nutrition programmes), while five propose generic frameworks that can be applied to efforts to scale up a range of public health endeavours [
7,
9,
24‐
26]. Generic frameworks will be examined more closely as they have the greatest potential to guide public health action across many areas.
The oldest of these generic frameworks, the scaling up management (SUM) framework, was developed by Kohl and colleagues in 2003, and was updated in 2012 [
24,
38]. It proposes three key steps with a series of tasks under each step. The first step involves developing a scaling up plan and creating a vision of what scaling up will look like if successfully implemented. Step 2 involves establishing the preconditions for scaling up, with key tasks including building the legitimacy of the intervention and the proposed approach, constituency building and realigning and mobilising resources. In the final step, the scaling up process is implemented based on the identification of factors that can promote extension and sustainability. Key tasks involve modifying organisational structures, coordinating action and performance monitoring.
The WHO and ExpandNet (2010) [
7] model developed by Simmons, Ghiron, Fajans and Newton based on earlier work by Simmons and Shiffman (2007) [
39] offers a slightly different way of systematically thinking about scaling up and was developed in light of the literature and expert opinion. The conceptual model accompanying the framework consists of five elements, with the scaling-up strategy as the centrepiece and five strategic choice areas (dissemination and advocacy; organisational process; cost and resource mobilisation; monitoring and evaluation). The framework is guided by four key principles which are systems thinking; a focus on sustainability; the need to determine scalability; and respect for gender, equity and human rights principles.
The framework proposes nine steps for developing a scaling-up strategy that involve the following: i) planning actions to increase the scalability of the innovation; ii) increasing the capacity of the user organisation to implement scaling up; iii) assessing the environment and planning actions to increase the potential for scaling-up success; iv) increasing the capacity of the resource team to support scaling up; v) making strategic choices to support vertical scaling up (policy, political, regulatory, resourcing or other health systems changes needed to institutionalise the innovation); vi) making strategic choices to support horizontal scaling up (replicating innovations in different geographic sites or extending them to serve larger or different population groups); vii) determining the role of diversification; viii) planning actions to address spontaneous scaling up; and ix) finalising the scaling-up strategy and identifying next steps.
Table 2
Synthesis of public health scaling up models and frameworks
Scalability considerations | Scalability with a focus on the following: | Health promotion: generic | Literature review and expert Delphi process | High-income country | |
➢ Effectiveness |
➢ Reach and adoption |
➢ Human, technical and organisational Resources |
➢ Costs |
➢ Intervention delivery |
➢ Contextual factors |
➢ Appropriate evaluation approaches |
Scaling up population health interventions: guide, New South Wales Ministry of Health | A 4-step process for scaling up interventions: | Public health: generic | Literature review and expert Delphi process | High-income country | |
➢ Step 1. Scalability assessment: to assess the suitability of the intervention/s for scaling up |
➢ Step 2. Develop a scaling up plan: create a vision of what scaling up will look like and a compelling case for action |
➢ Step 3. Prepare for scaling up: securing resources and building a foundation of legitimacy and support for the scaling up plan |
➢ Step 4. Scale up: the main tasks that should be addressed during scale up |
9 steps to scaling up, WHO ExpandNet | ExpandNet framework involves 9 steps: | Health services and public health: generic | Literature review and interviews | Global health | |
➢ Planning actions to increase the scalability of the innovation |
➢ Increasing the capacity of the user organisation to implement |
➢ Assessing the environment and planning actions to increase the potential for success |
➢ Increasing the capacity of the resource team to support scaling up |
➢ Making strategic choices to support vertical scaling up (institutionalisation) |
➢ Making strategic choices to support horizontal scaling up (expansion/replication) |
➢ Determining the role of diversification |
➢ Planning actions to address spontaneous scaling up |
➢ Finalising the scaling-up strategy and identifying next steps |
Scaling up management (SUM) framework | Includes 3 key steps: | Health services and public health: generic | Literature and interviews | Global health | |
➢ Step 1: developing a scaling up plan |
➢ Step 2: establishing the preconditions for scaling up |
➢ Step 3: implementing the scaling up process based on the identification of factors that can promote extension and sustainability |
Scale up of exclusive breastfeeding | Involves the following steps: | Health services and public health: breastfeeding | Systematic review | Global health | |
➢ Assess situation, create a policy environment conducive to action |
➢ Define roles, relationships and responsibilities of all partners |
➢ Establish agreements |
➢ Review technical support |
➢ Define programme strategy |
➢ Mobilise resources |
➢ Provide training and technical assistance |
➢ Develop and use monitoring and evaluation systems |
➢ Monitor coverage and quality |
➢ Measure impact and cost |
➢ Provide for testing novel approaches and continuing innovation |
Scaling up global health interventions: framework for success | Describes 6 components of the scaling up process: | Health services and public health | Literature review and interviews with experts | Global health | |
➢ Attributes of the specific tool or service being scaled up |
➢ Attributes of the implementers |
➢ Chosen delivery strategy |
➢ Attributes of the ‘adopting’ community |
➢ Socio-political context and research context |
Breastfeeding gear model | Eight interrelated elements: | Health services and public health | Literature review, interviews and focus groups | Global health | |
➢ Advocacy |
➢ Political will |
➢ Legislation and policies |
➢ Funding and resources |
➢ Training and delivery |
➢ Promotion |
➢ Research and evaluation |
➢ Coordination and goals monitoring |
The framework suggests successful multiple feedback loops and several potential paths are required to achieve intended innovation |
Yamey (2011) [
9] offers a framework and key success factors for scaling up global health initiatives based on a literature review and interviews with ‘thought leaders’. Yamey’s framework divides the scaling up process into six categories: attributes of the specific tool or service being scaled up; attributes of the implementers; the chosen delivery strategy; attributes of the ‘adopting’ community; the socio-political context; and the research context.
Each of Yamey’s categories will now be examined in greater detail, starting with the attributes of the specific tool or service being scaled up. Keeping the intervention simple is considered a predictor of success [
40,
41], and technical experts who have managed large-scale implementation also argue that getting the implementation policies and procedures scientifically robust and evidence informed before going to scale is crucial for success [
42].
Addressing the attributes of the implementers, the framework suggests that strong leadership and governance play an important role in successful scale up as is getting buy-in from local implementers and other key stakeholders. The framework also recommends using both state and non-state actors as implementers.
The chosen delivery strategy is also of great importance, with the framework recommending the application of diffusion of innovation theory by focusing on the five factors identified by Rogers (1995) [
43] as being positively associated with the faster diffusion of an innovation. The framework also describes cascade and phased approaches to scaling up depending on the context within which an intervention is delivered. Cascade approaches use a ‘train the trainer’ approach that can result in rapid expansion of interventions. Going to scale in a phased manner begins with a pilot programme, followed by stepwise expansion and learning lessons along the way to help refine further expansion. Tailoring scale-up to the local situation and decentralising delivery by adopting an integrated approach to scale-up is also considered important.
Thinking about the attributes of the adopting community can be facilitated through the active participation of the community in planning, implementing, and monitoring interventions and is cited as a crucial factor in successful scale-up. Being cognisant of the socio-political context is a vital consideration in the framework, particularly building political good will and alignment with national policies. Finally, the framework requires due consideration of the research context. This can be done by incorporating research into implementation using ‘learning and doing’ approaches that involve the systematic application of evidence to guide the process and incorporate new learning.
Milat and colleagues developed a model of ‘scalability considerations’ using a literature review and expert Delphi process in 2012 [
25], which was further developed in 2013 into the ‘increasing the scale of population health interventions guide’ [
26] for the NSW Ministry of Health in Australia. The framework proposes a four-step process for scaling up interventions. It differs from other models discussed as it is specifically designed for scale-up of public health interventions in high income countries and is unique in that step 1 involves a ‘scalability assessment’ that determines the suitability of the intervention/s by assessing effectiveness, potential reach and adoption, alignment with the strategic context and intervention acceptability and feasibility. The outcome of this assessment will determine whether the remaining steps in the guide should be followed.
Step 2 describes how to develop a scaling up plan which should create a vision of what scaling up will look like and a compelling case for action. This step involves documenting a rationale for scaling up, describing the intervention, completing a situational and stakeholder analysis, determining who could be involved in scale up and what their role will be, selecting an approach to scaling up, considering options for evaluation and monitoring and estimating resources required for scale up and writing up the plan.
Step 3 describes how to prepare for scaling up by securing resources and building a foundation of legitimacy and support for the scaling up plan process. This step involves consultation with stakeholders, legitimising change, building a broad constituency and realigning and mobilising resources. Finally, step 4 describes the main tasks that should be addressed during scaling up including modifying and strengthening organisations, coordinating action and governance, monitoring performance, quality and efficiency and ensuring sustainability.
Though many of these frameworks propose linear processes for scaling health interventions, it is acknowledged by their authors that the reality of ‘real world’ scale-up is that one or more steps in scale up are often missed. For example, using the Milat et al. 2014 model as an example, initiatives often go from a scalability assessment (step 1) to full implementation (step 4), without establishing important preconditions for success such as building a broad constituency and realigning and mobilising resources [
8,
19,
26].
A common characteristic of scaling up models identified in this review is that they link many existing concepts in the literature and interpret them together and in relation to one another to illuminate factors that inform large-scale implementation of public health interventions. Common characteristics of these models include a focus on understanding the attributes of the intervention being scaled up (effectiveness, potential reach, acceptability etc.), identifying and supporting implementers, the selection of an appropriate delivery strategy, understanding and accommodating the characteristics of the adopting community, taking into account the broader socio-political context, and the use of research, evaluation and monitoring data to inform the scale-up process. Importantly, these frameworks enable a clearer discourse and common understanding of key concepts and methods associated with the scale-up of public health interventions.
Success factors and barriers to effectively scaling up public health interventions
Key success factors for scaling up health interventions gleaned from this review, particularly from case studies and papers that interviewed implementation experts in order of frequency of mention in the literature are the following: establishing monitoring and evaluation systems [
5,
7,
11,
13,
17,
20,
25‐
27,
29‐
31,
44]; costing and economic and other modelling of intervention approaches [
10,
12,
13,
16‐
18,
20,
23,
24,
28,
32,
44]; active engagement of a range of implementers and the target community [
7,
9,
13,
17,
20,
25‐
27,
29,
31,
44]; tailoring the scale-up approach to the local context and use of participatory approaches [
5,
7,
13,
17,
26,
29,
41,
44]; systematic use of evidence [
7,
9,
13,
17,
26,
31,
44]; infrastructure to support implementation such as training, delivery systems, technical resources [
13,
17,
20,
27,
31,
32,
44], strong leadership and champions [
7,
9,
13,
17,
25,
44]; political will [
7,
9,
17,
25,
32]; well defined scale up strategy [
9,
13,
24,
27,
44]; and strong advocacy [
7,
9,
12,
22,
27] (See Table
3).
There is merit in more closely examining some of these success factors starting with the importance of the use of evidence. It was widely noted in papers that effective scale-up requires the systematic use of different types of evidence. For example, Simmons and Shiffman [
39] argue that successful scale-up ‘…requires the systematic use of evidence to guide the process and incorporate new learning.’ It was also noted that quality control and performance monitoring systems should replace stand-alone evaluation as interventions increase further in scale and are disseminated widely into policy and practice.
Table 3
Synthesis of success factors and barriers to scaling up public health interventions in rank order of mentions
Success factors | Bibliographic references |
Establishing monitoring and evaluation systems | |
Costing and economic modelling of intervention approaches | |
Active engagement of a range of implementers and the target community | |
Tailoring scale-up approach to local context and use of participatory approaches | |
Systematic use of evidence | |
Infrastructure to support implementation such as training, delivery systems, technical resources | |
Strong leadership and champions | |
Political will | |
Well-defined scale-up strategy | |
Strong advocacy | |
Flexible responses to human resource constraints | |
Formative research to ensure appropriate intervention design | |
Equity of intervention delivery and monitoring intended and unintended consequences across socio-demographic profiles | |
Effective communication strategy | |
Effective governance and coordination | |
Clear role definition and delineation | |
Keeping the intervention model simple | |
Financing models | |
Programmes are visible, publicised and effectively packaged | |
Developing strategies for integration into existing services | |
Barriers | |
Not adapting intervention approaches to the local context | |
Intervention costs and other economic factors | |
Lack of human resources | |
Resistance to the introduction of new practices due to capacity constraints | |
Insufficient investment in implementation infrastructure including training, monitoring and evaluation systems | |
Staff recruitment and staff turnover | |
Lack of political will | |
Traditional research funding processes are not flexible enough to support evaluation of scale up | |
Leadership changes amongst implementation agencies | |
Poor engagement with stakeholders and thought leaders | |
Poor role delineation | |
Maintaining quality and consistency of health interventions at scale [ 18] | |
Information on programme costs and other economic considerations were considered fundamental to making effective decisions about the appropriateness and feasibility of population-level programme implementation. Failure to address economic outcomes was often noted as a barrier to scale-up and the presence of this data was conversely considered an important facilitator of effective decision making.
Consideration of the context within which interventions are delivered was widely identified as an important success factor. Tailoring the scale-up approach to the settings within which they operate such as community characteristics, financial and human resources and local socio-political landscape was thought to be facilitated by the use of participatory approaches that include active engagement of a range of implementers and the target community.
Barriers to successful scale-up of public health interventions identified in the review were often the converse of the success factors and ranged from the following: not adapting intervention approaches to the local context [
18‐
20,
24], intervention costs and other economic factors [
12,
22,
25,
32], lack of human resources [
13,
18,
19], resistance to the introduction of new practices due to capacity constraints [
18,
19,
26], insufficient investment in implementation infrastructure including training, monitoring and evaluation systems [
17,
18,
45], staff recruitment and staff turnover [
18,
19,
46] and lack of political will [
9,
32].
There were a number of challenges identified in the literature to moving interventions from a ‘research’ phase to a widespread adoption or scaling up phase in high-income countries. Norton and Mittman’s [
19] examination of barriers and enablers to scaling up ten promising health promotion and disease prevention interventions in the USA found that many of the organisations implementing the programmes during initial research phases viewed the programmes as experimental and time-limited, and were reluctant to have interventions become fully integrated into the organisation’s routine service delivery after the study. They also found that a number of research teams were subsequently unable to implement the programme according to original experimental protocol in real world settings using community-based organisations (e.g. senior centres), and had to adapt the interventions to fit typical organisations with limited resources.