Scaling-up Innovations
in Public Health
Nancy Edwards
Professor, University of Ottawa,
Scientific Director,
Institute of Population and Public Health
Canadian Institutes of Health Research
Canadian Institutes of Health Research
Institute of Population and Public Health
Health Equity Matters
http://www.cihr.ca/e/13777.html
Approach
• Reviewed all titles from assembled
literature to identify relevant studies
• Identified public health “scenarios” that
reflect different classes of innovation
• Limited search for recent articles/reports
(including review articles and case
studies) pertinent to scenarios
Scaling-up
Common Elements of Definitions
• Series of processes to introduce innovation(s)
with demonstrated effectiveness
• Processes involve organizational and/or political
intentionality
• Aim for sustained improvements in coverage of,
and equitable access to the innovations
• Require program delivery structure/strategy
Classes of Innovation
• Discrete
• Multi-component and multi-level
• Paradigmatic
Classes of innovation
Class of
Innovation
Characteristics
Discrete
(e.g. vaccines, fluoride
in drinking water)
Well-defined, specific dose and delivery parameters,
demonstrated efficacy and effectiveness, packaged for
ease of delivery.
Multi-component and
multi-level
(e.g. tobacco control
and childhood obesity
prevention strategies)
More complex, less prescriptive, less structured than
discrete innovations.
Program components may be required to act
synergistically to yield their intended benefits; require
adjustment to both characteristics of target population
and dynamic implementation contexts.
Paradigmatic
(e.g. determinants of
health approach,
health in all policies)
Involve a major conceptual shift in the way we think
about issues and their solutions.
Systems-wide approach and complex set of
partnerships.
Key Factors Limiting Scale-up (1)
• Underestimating type and quantity of resources
required
– Implementation capacity - human, financial,
infrastructural investments
– System absorption capacity – governance,
administrative, accountability and financial systems
• Political and/or policy naivety
– Not understanding actors involved – failure to get
issue on policy agenda
– Lack of long-term political commitment
– Vested interests
Key Factors Limiting Scale-up (2)
• Lack of attention to potential for scaling-up
and sustainability during initial testing of
innovation
• Inattention to demand side of scale-up
– Push versus pull
• Over-emphasis on either vertical or
horizontal spread of innovations
Key Factors Limiting Scale-up (3)
• Inattention to temporal dimensions of
scale-up
– Spatial dimensions – coverage, reach,
availability and accessibility of services
– Temporal dimensions – differential rate of
change at each system level
Public Health Scenarios
• H1N1 vaccination
• Tobacco control
• Policy change and built environment
H1N1
Key Learnings
• preparing for a range of potential epidemic
scenarios
• deploying an ethical and cost-effective approach
to distribute a limited resource (vaccine and
tamiflu)
• media rapidly increased the demand side for
vaccines
• scale-up constrained provision of other essential
public health services
• Highlighted importance of a systems approach
for effective scale-up
H1N1
Research Questions
• What gets scaled-down and what are the short
and long-term impacts of scaling-down
programs when surge responses are required to
deal with a public health crisis?
• What are the critical elements required for
components of a system (both those under the
authority of health ministries and those outside
their authority) to work most effectively as a
responsive and adaptive system for rapid scaleup?
Tobacco Control
Key Learnings
• government commitment at all levels essential to
resource a comprehensive and long-term multifaceted tobacco control strategy
• coalitions and alliances maintained momentum
towards tobacco reduction goals
• monitoring and evaluation systems informed
decisions about progress (e.g. shifts in patterns
of tobacco use and types of tobacco used)
• constant vigilance has been required to identify
counter measures by the tobacco industry
Tobacco Control
Research Questions
• What can be learned about successful
efforts to scale-up the adoption of lifestyle
changes by the private sector within and
across jurisdictions?
• How do national and international
conventions on product control (e.g.
control of tobacco products) exert their
influence within and across jurisdictions?
Policy and built environment
Key Learnings
• enduring and omnipresent influence of the built
environment on all types of human activities
• other sectors play key role in planning,
designing and constructing the built environment
• built environment exemplifies historical and
structural influences that create system rigidity,
potentially reinforcing inequities across social
strata
Policy and built environment
Research Questions
• Does modeling the projected scaled-up
impact of the built environment shift
decisions about options for land use,
urban design, transportation corridors or
housing developments?
Highlights - What we know
• Scaling up involves a complex chain of
pathways, and adaptive changes to the
innovation in a dynamic context
• Many factors external to the innovation influence
scale-up including system absorption capacity,
governance mechanisms, partnerships, political
will, leadership, and financial accountability
structures
• Policy windows of opportunity may set the stage
for initiating scale-up change processes, while
alliances may help maintain momentum for
longer-term scale-up
• Both horizontal and vertical dimensions of
scaling-up are important
Highlights - What we don’t know
• Approaches to scale-up that optimally
strengthen equity, while improving overall health
status.
• Direct and indirect costs of scale up.
• What is required for initial versus sustained
scale-up.
• Comparative effectiveness of approaches to
scaling up-across classes of innovations and
under a range of contextual conditions
(governance, financing, leadership, political
support).
• Intersection of scaling-up and scaling-down
processes.
Recommendations - Highlights
• A typology for classes of innovation in public health
requires further development.
• A framework is needed for the contextual analysis of
scale-up.
• Research on the scale-up of public health innovations
should include equity outcomes.
• Temporal dimensions of scaling-up require further study.
• Identify what monitoring and feedback systems are
needed to better capture scaling-up processes and
integrate these systems into the planned scale-up of
large initiatives.
• De-scaling - how to remove innovations that have
already gone to scale - warrants more attention.