Institute of Development Studies

Scaling Up for Health

Lawrence Haddad - 11 December 2008 

The term scaling up has many meanings in the health community. The essence of the term is to significantly increase the effective use of a technology, process or idea. But there are many ways of doing this, and many lessons that have been learned the hard way have not been shared.

The conference on Scaling up for Health organised by BRAC, the Gates Foundation and the Rockefeller Foundation in Dhaka in early December 2008 aimed to fill this gap, looking at the challenges and some of the next steps for practitioners, researchers, governments and donors.

Key Points from the Conference

• Scaling up needs to be planned for at the outset. The need to think about scaling at the first stage is vital for the scaling of processes, which are more likely to be affected by culture, power and perception.
• Scaling up requires a different set of skills to that necessary for developing the technology, process or idea. Political analysis is needed to understand who will win and who will lose. Institutional analysis is needed to assess capacity to scale up and the changes needed in regulatory frameworks. Mobilisation skills are needed to generate demand. Communication skills are needed to craft messages that enhance effective use. Risk assessment is needed to anticipate risk and have a plan for managing shocks.
• Scaling up requires a willingness to acknowledge failure and learn from it. Many scaling up events will not work at first and some not at all. Problems need to be solved as they arise, and plan B must be able to be quickly formulated and implemented. 
• M&E needs to take place during scale up. Most M&E is conducted at a predetermined scale in a pilot. It needs to be flexible and distinguish between effectiveness of the intervention and the effectiveness of the scale-up. Finally, costs need to be collected at the originator and roll out phase.

Notable Absences from the Conference Presentations 

• Not enough about failures. Which events helped them learn the most? How fragile was the journey to success and what support did they draw upon?
• What about scaling down, scaling out? Scaling up implies doing more of something, which often means doing less of something else. With unpredictable funding flows, it is important to know how to manage these scale downs. The way in which scale down occurs can maximise options for later scale ups and prevent unintended consequences for affected populations. 
• Uneven scaling. Most of the scale ups had expanded coverage as a goal. But unplanned scaling up will inevitably follow the path of least resistance, and tend not to be in the remotest areas or with the most excluded groups. 
• Donor support to scaling up is not straightforward. Are donors simply financiers, or co-producers in scale up with their know-how and networks? Often their key performance indicator is how much money they can spend. ‘Overfunding’ can lead to unsustainable behaviour in the grantees. 
• The health sector needs to change. Perhaps the biggest hidden assumption among participants was the sense that the health sector could somehow work out scaling up in the twenty first century with a twentieth century approach.

The health community needs to scale up its ability to scale up

First, the health sector needs to agree on what scaling up is, or agree on what the disagreements are and commit to on-going dialogues – or the costs of muddled thinking will also be scaled up.

Second, the health sector needs to be more inclusive. Not everything can or should be evaluated in a randomised controlled trial. The health field needs to become more comfortable with a range of social science methods and notions as to what constitutes evidence.

Third, the sector needs to go beyond health to achieve effective health scale ups. While some sectoral knowledge is probably important for effective health scale up, much of the know-how can cross sectoral boundaries. There is much to learn from microfinance, ICT and the private sector.

Finally, the big players need to practice what they preach. BRAC’s highest velocity scale ups right now are probably in Africa. BRAC needs to document these experiences with brutal honesty—for itself and for the wider field. Similarly foundations such as Rockefeller and the Bill and Melinda Gates foundation need to reflect on how their own behaviours may affect scale up. Does overfunding occur, and does it lead to less sustainable and more unequal systems - and can these be justified in terms of immediate benefits?

Such interventions require not only a scaling up of the health sector’s ambitions, but also a scaling down of its certainties and a scaling up of its inclusiveness and relationship building. As it is often said, it’s important to make friends on the way up, because you will need them if you ever find yourself on the way down.

Lawrence Haddad is Director of IDS