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Many PHE initiatives fail to expand to new areas because they were not designed and implemented with this goal. The HoPE-LVB project was unique in this regard. Using guidance developed by ExpandNet/WHO14 that lays out key principles for working with this so-called scaling up focus led to a different kind of approach and one that has yielded substantial influence on how PHE integration is viewed in the East Africa region as a result. This chapter lays out key aspects of this experience, in an effort to provide guidance to newcomers to PHE implementation to select, implement and strategically manage your PHE initiative in similar way. Much more about the HoPE experience applying the “beginning with the end in mind” guidance is laid out in a peer-reviewed article published in Reproductive Health Matters.
In addition, this chapter touches on the experience of HoPE applying a multi-stakeholder scaling up strategy development process using ExpandNet/WHO guidance entitled Nine Steps for Developing a Scaling Up Strategy. The Nine Step Guide is built around the ExpandNet/WHO framework, which is laid out briefly below. The chapter ends with some indications of what has evolved since the scaling up strategy development workshops with the scaling-up process.
The following ExpandNet/WHO definition of scale up helped to guide HoPE-LVB throughout:
“Deliberate efforts to increase the impact of successfully tested pilot, demonstration or experimental projects to benefit more people and to foster policy and programme development on a lasting basis.” (ExpandNet/WHO 2010)
The definition stresses that for scaling up to succeed it must be guided, since leaving the process to chance has not had the desired impact. The definition also stresses that interventions that one wishes to scale up must be based on strong evidence of effectiveness and feasibility. Finally, in order for interventions to have lasting, sustainable impact, they must focus both on expansion to benefit more people and on becoming institutionalized in policies and programs. The former—namely expansion (to benefit more people)—is one type of scaling up; whereas the latter—institutionalization—seeks to embed the interventions in systems, policies, laws, budgets, curricula, etc. These are the two most important types of scale up.
The decades of experience and learning ExpandNet has assembled on what makes scale up succeed has been packaged into several guidance tools and resources to support implementers, policy makers, program managers, researchers and technical assistance personnel. ExpandNet learned that it is never too soon to think about scaling up. Therefore, projects that have hopes for large-scale, sustainable impact should use the scale-up learning that exists and use it to design and implement the approach being tested. The tools mentioned build on ExpandNet’s scaling-up framework that helps to analyze all the elements that must be understood and the choices that must be made in order for scaling up to be successful.
ExpandNet suggests that the entire system in which scale up is taking place must be taken into consideration when designing, implementing and scaling up PHE interventions. As illustrated in the below figure, the system is comprised of not just 1) the key pieces in the package of PHE interventions (called “the innovation” in the language of the framework); but also 2) the “user organizations” who would eventually adopt and implement the innovation on a larger scale; 3) the “resource team” who seeks to support the process of scale up; and 4) the larger socio-cultural, economic, political and bureaucratic environment in which scale up will take place. It is the “scaling up strategy” that ensures the innovation is scaled up into wider use within the user organizations, with the strong support of the resource team.
Keeping this framework in mind, the HoPE team set to work towards achieving their strategic objective to “Develop and demonstrate/test a model for PHE integration in LVB sites that can be adapted and scaled up in communities, as well as by local, national and regional governments.” This meant taking action towards as many as possible of the 12 recommendations put forth by ExpandNet/WHO to begin with the end of scaling up in mind.
A table that illustrates key actions taken by HoPE is below:
The fact that HoPE worked to address as many of the above recommendations as possible helped position the project well for undertaking a planning process for scaling up with a wider range of stakeholders at the beginning of Phase II, which was focused squarely on supporting scale up to new areas and to institutionalize HoPE interventions. In February 2015, the team organized scaling up strategy development workshops in Kenya and Uganda based on the ExpandNet/WHO guidance “Nine steps for developing a scaling up strategy.” During these meetings, a wide range of stakeholders in both countries provided their key recommendations for actions that would help ensure that the innovation would reach more people and ideally be sustained over time. The strategies coming out of the workshops in both countries are available in the Appendix.
Subsequently managing the scaling up process during Phase II yielded many critical insights about both the successes as well as the complexities of implementing HoPE approaches more widely. This experience is being described in a forthcoming journal article that will be available on the Pathfinder International1 website.
1 Pathfinder International
To see all HoPE-LVB tools, visit Section 6 of our Toolkit.