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HopeLVB Toolkit

Table of Contents

Section 4: Scaling up a PHE Program

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.

4.1 Scaling Up Defined

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.

4.2 ExpandNet/WHO Framework for Scaling 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:

Recommendations for “Beginning with the End in Mind”

Examples of Actions taken by HoPE-LVB

1. Engage in a participatory process involving key stakeholders
  • Conducted ongoing group and individual meetings/interviews with a variety of community-based groups, district/county officials, national line ministry representatives and regional East African leaders to gain input on implementation and prospects for sustainability and scaling up
  • Established Uganda national and Kenyan county-based PHE steering committees
  • Organize site visit opportunities with academic institutions, advocates, donors and other key stakeholders related to the P, H, and E sectors
  • Establish and support a network of PHE champion/advocates at local, subcounty, district/county, national and regional levels


 2. Ensure the relevance of the innovation (HoPE-LVB package of interventions) to local and national contexts
  • Conducted rapid assessments with community members in project areas to select and determine how best to implement HoPE-LVB interventions
  • Analyze the initially proposed interventions in light of stakeholder input and the determinants of scaling-up success
  • Carry out extensive community advocacy and resource mobilization
  • Create focused activities specifically on integration
  • Implement interventions according to national guidelines


3. Reach consensus on expectations for scale up
  • Project team meets and clarifies objectives, modalities and expectations of scaling up
  • Identify future stakeholders/project holders in advance and begin advocacy to get their buy-in early on


4. Tailor the innovation in the variety of socio-cultural and institutional settings where it will be scaled up
  • Participate in district health management team meetings and national level working groups
  • Work with teachers to implement PHE programming as school activities


5. Keep the innovation as simple as possible
  • Pare down the number of interventions and reduce each to its most essential components as simple innovations are easier to scale up


6. Test the innovation in the variety of sociocultural and institutional settings where it will be scaled up
  • The HoPE-LVB project started in two countries, Kenya and Uganda and operated in island and mainland communities around the Lake Victoria Basin, which allowed for different strategies to develop locally and be adapted through crosslearning.


7. Test the innovation under the routine operating conditions and existing resource constraints of the system
  • Instead of training new hires, train government representatives as “training of trainers” whose task is to implement similar initiatives


8. Develop plans to assess and document the process of implementation
  • Develop a simplified tool to document the implementation process (the how) that is not captured in monitoring and evaluation (the what).
  • Track what is being learned about working towards sustainability and scaling up so others may successfully replicate project interventions in the future


9. Advocate with donors and other sources of funding for financial support beyond the pilot stage
  • Dedicate project funding from the outset for strategic advocacy
  • Invite visitors to project sites to stimulate interest
  • Signed MOU with the Lake Victoria Basin Commission with joint fundraising as one of the potential activities
  • Country level fundraising
  • Generate positive media coverage
  • Register local community groups as NGOs so they could be eligible for competing for government grants and funds


10. Advocate for necessary changes in policies, regulations, and other systems components to create enabling environment for future scale up
  • Identify and train PHE champions in the community to advocate for PHE and HoPE-LVB approaches
  • Conduct policy reviews at baseline
  • Continue to learn about existing policies, plans, regulations, operational guidelines on P, H and E
  • Link national advocacy to global advocacy topics and events
  • Work to strengthen health systems that has lasting impact
  • Participate in meetings of sub-county councils, district health management teams, national level health working groups, and more
  • Work with local policymakers and village communities on by-laws to codify some of the useful health and conservation practices


11. Promote learning and disseminate information about HoPE-LVB
  • According to workplans, and also on an ad hoc basis, make presentations at global, regional and national conferences
  • Publish information about HoPE-LVB and release to the public on website to reach wide audiences
  • Participate actively in the PHE network to share information
  • Use social media, such as blogs and tweets, to further publicize the existence of HoPE-LVB documentation
  • Disseminate HoPE-LVB approaches and preliminary findings via district, national and international meetings and conferences where targeted decision-makers are in attendance
  • Orient media personnel on PHE in general so they are able to disseminate project experience and PHE approaches in general


12. Gather required evidence on the implementation process for scale-up
  • Conduct mid-term review, make course corrections
  • Continue to review whether HoPE-LVB interventions are feasible, acceptable, effective and efficient; whether they improve outcomes under routine conditions in a large scale program
  • Simplify HoPE-LVB even further and identify a minimum package
  • Careful documentation and creation of a ‘toolkit’ to share lessons

 

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

Looking for More Resources?

To see all HoPE-LVB tools, visit Section 6 of our Toolkit.

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