Commentary

Managing scaling up: what are the key issues

Datos Bibliográficos

ID11490264
AutoresLucy Gilson (0000-0002-2775-7703, University of Cape Town, autor de correspondencia), Hp Schneider (0000-0002-0418-1828, University of Cape Town)
Año2010
Volumen25
Número2
Páginas97-98
Fecha de publicación2010-03-01
Peer ReviewedSí
Open AccessSí
TipoARTICLE
RevistaHealth Policy and Planning (JOURNAL)
Identificadores de la revistaISSN: 0268-1080 • E-ISSN: 1460-2237
EditorialOxford University Press (PUBLISHER • GB)
DOI10.1093/heapol/czp067
PMID20053734
OpenAlexW1999161797
IdiomaEN
Citas recibidas7
Referencias citadas8

We want to pick up and expand on two sets of inter-related issues raised in the paper by Mangham and Hanson (2010): the importance of political commitment and of strategic management to scaling up. As the paper makes clear, these issues are integral to successful scaling up. Evidence on progress towards the Millennium Development Goals, for example, demonstrates the need for strong government leadership, whilst policy and strategic management is one of the five barriers recognized to constrain expansion of health interventions’ coverage. But, as the paper also shows, within scaling up debates little attention has so far been paid either to how to generate political commitment to scale up public health interventions, or to the nature of the strategic management also required to support this process. Yet there is (some) relevant health evidence, as well as relevant theory, around policy implementation (e.g. Hill and Hupe 2002) and innovation (Greenhalgh et al.2004), from which to draw useful insights. First, we look at political commitment. For low- and middle-income settings there is a relatively rich body of empirical work examining how policy agendas are set, including the transfer of policy ideas between international and national jurisdictions (Gilson and Raphaely 2008). This work critiques the idea that political will is the central determinant of successful policy change (Reich 1995). Instead, it shows how political commitment to a new policy or programme has to be actively created, essentially through advocacy. Examining maternal health policy experience, Shiffman (2007) highlights the importance of alliance building to consolidate influence, working with political entrepreneurs to get public health issues onto policy agendas, using credible measures to demonstrate the severity of the problem addressed through a new programme and avoid denial of its importance, organizing focusing events to publicize the issue and presenting policy makers with policy alternatives of proven effectiveness which show them the problem can be addressed. These sorts of advocacy efforts may also be important once an issue or programme is on the policy agenda, to secure sustained domestic budgetary commitments (Crichton 2008). When international actors seek to influence national policy agendas, they are, therefore, likely to be more effective when they work as advocates of change rather than adopting more coercive approaches (Walt et al.2004). Second, managing scaling-up processes. Although the precepts of rational planning (such as developing objectives and resource requirements, prioritizing activities, sequencing implementation and monitoring and evaluation) are important when initiating the scale-up of new public health interventions, successfully sustaining the implementation of interventions over time is a complex process requiring considerable managerial flexibility and strategic flair. Such interventions represent innovations: they are based on the implementation of new (or the adaptation of existing) knowledge through new activities, and/or new ways of conducting usual activities (Osborne and Brown 2005). Review of innovation experience in the reproductive health field emphasizes that scaling up is not just about technology transfer and information dissemination, but instead is essentially a learning process in which the adaptation of the innovation to local realities is vital. It always involves a complex set of social, political and institutional processes occurring within a web of interacting forces, in which multiple actors, interest groups and organizations must be engaged whilst taking account of wider contexts (Simmons et al.2006). Other health sector empirical evidence supports these insights. In Ceara State, Brazil, for example, the scaling up of a community health worker (CHW) programme in the early 1990s, and achievement of positive health impacts, was supported by the underlying management processes. These created a strong programme mission, allowed local flexibility in implementing programme guidelines, and combined centralized and decentralized control. As a result, opposition to the programme was defused, popular support was secured and CHWs and supervisors were motivated to fulfil programme goals (Tendler and Freedheim 1994). In South Africa, meanwhile, the scaled up use of syndromic management guidelines in the treatment of sexually transmitted infections was also enabled by a flexible process of implementation across the country. Different provincial administrations initially adopted different approaches and proceeded at different paces. But over a fairly short space of time, by sharing experience they came to accept a common set of guidelines (Schneider et al.2006). In contrast, partly in response to international pressure, the TB DOTS programme adopted an inflexible package and forced pace of scaling up. This process ignored the considerable on-the-ground experience and knowledge within the country, and resulted in programme resistance in several provinces (Schneider et al.2006). More specific approaches identified as important in managing reproductive health scaling-up processes are highlighted in Box 1. Ulimately, however, an innovation can only be sustained over time and place through institutional development—that is, by reorienting existing organizational norms, values, incentives and traditions to encourage implementing actors to support the new way of doing things that an innovation inevitably entails (Simmons et al.2006; Simmonds 2008). Source: Simmons et al. (2006). Clear messages through which the advantages of innovations are made visible Personal contact and informal communication Early involvement of the innovation’s users Adaptation of the innovation to local contexts Participatory approaches of implementation Allowing sufficient time for implementation Strong diffusion channels Training support to ensure skills transfer Systematic use of evidence on the process and outcomes of scaling up An ongoing focus on sustainability So, although there is no simple recipe for managing scaling-up processes (Greenhalgh et al.2004), experience both from within and outside the health sector offers relevant insights. It suggests that extending the coverage and reach of a new public health intervention will only be possible over time. It will require deliberate efforts to build support for, and understanding of, the intervention. This may require, in some instances, adaptation both of the innovation itself and of the wider health system in which it is implemented. International actors seeking the scale-up of new interventions must, therefore, plan on providing long-term and sustained support to the managers and health workers charged with their implementation, encouraging learning and promoting the sharing of experience. Closer examination of how scaling-up experiences are initiated, led and managed over time will also provide a deeper knowledge base from which to derive further lessons.

Alliance · Government (linguistics) · Health care · Policy transfer · Political science · Politics · Psychological intervention · Public policy · Public relations · Sociology · Global Maternal and Child Health · Global Public Health Policies and Epidemiology · Health Policy Implementation Science · Medicine · Nursing · Public Administration · Health Policy