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Scaling-up Health Innovations and Interventions in Public Health: A Brief Review
of the Current State-of-the-Science
Nancy Edwards, RN, PhD
Professor,
School of Nursing and Department of Epidemiology and Community Medicine,
University of Ottawa, Ottawa, Canada;
Scientific Director,
Institute of Population and Public Health,
Canadian Institutes of Health Research
This paper was commissioned by the conference chairs for delegates of the inaugural Conference to
Advance the State of the Science and Practice on Scale-up and Spread of Effective Health Programs,
Washington, DC, July 6-8. Correspondence to N. Edwards (Nancy.Edwards@uottawa.ca).
Funding for this conference was made possible in part by grant 1R13HS019422-01 from the Agency for
Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or
publications and by speakers and moderators do not necessarily reflect the official policies of the
Department of Health and Human Services; nor does mention of trade names, commercial practices, or
organizations imply endorsement by the U.S. Government. The Commonwealth Fund, The Veteran’s
Health Administration, The Donaghue Foundation and The John A. Hartford Foundation also provided
meeting support.
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Scaling-up Health Innovations and Interventions in Public Health: A Brief Review
of the Current State-of-the-Science
Executive Summary:
The aim of scaling-up public health innovations is to improve coverage and
equitable access to the innovation(s) and their intended benefits. Scaling-up involves
processes to introduce innovations with demonstrated effectiveness through a program
delivery structure. In this paper, three classes of innovation of relevance to public health
are described. The first class is discrete innovations such as vaccines, fluoride in water
and Antiretrovirals for HIV/AIDS. The second class is multi-component interventions
that are synergistic and normally operate at more than one system level. Examples
include multiple intervention programs in the fields of tobacco and heart health. The
third class of innovations are paradigmatic and involve a shift in the way we understand
problems and needs, in what we consider to be viable solutions, in who we think should
be engaged in finding and implementing solutions, and in how we attempt to engage
them. Examples include applying a population health approach to interventions in public
health and introducing health in all policies,
A review of literature on scaling-up public health innovations yielded several
major challenges: a) underestimating the type and quality of resources required for scaleup; b) political and policy naivety; c) lack of attention to issues of sustainability and
scale-up during early efforts to test or implement innovation uptake; d) an over-emphasis
on either the vertical or horizontal spread of innovations; e) inattention to spatial
elements of scaling-up; and f) inattention to the demand side of scale-up.
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Several public health cases are examined in detail to illustrate approaches and
challenges in scaling-up. H1N1 immunization provides an example of a rapid systems
response to an epidemic using discrete interventions (vaccine and Tamiflu). This
example illustrates the importance of an integrated systems approach, coordinated
leadership, and attention to supply and demand requirements. The second case of
tobacco control highlights the long-term efforts required for scale-up, and addresses the
importance of alliances and networks that work across spatial parameters like
jurisdictions and temporal parameters like election periods. This case also reflects the
vigilance required to counter scale-up efforts by the tobacco industry. The third example
involves policy and the built environment. It illustrates how decisions made about the
built environment today have a long-term impact on perceived and real options for
scaling-up some public health interventions in the future. It reflects the robust staying
power of a paradigm (car is king) that challenges the introduction of new innovations and
their underlying paradigms (walkable environments). Both the tobacco and built
environment examples underscore the importance of social movements in shaping and
supporting momentum for scaling-up efforts. They also remind us that health disparities
may be introduced or reinforced when scaling-up innovations if underlying structural
influences on disparities are not addressed.
Following a summary of what we do and do not know about scale-up in public
health, several key recommendations are provided.
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Scaling-up Health Innovations and Interventions in Public Health: A Brief Review
of the Current State-of-the-Science
Introduction:
This is one of several papers that have been prepared for the invitational meeting
on the science and practice of scale-up and spread in Washington, D.C., July 6-8th, 2010.
The purpose of this paper is to describe the scaling-up literature as it relates to the field of
public health and to identify priority areas for scientific inquiry in this field. The concept
of scaling-up is introduced and pertinent definitions of scaling-up are considered.
Features of innovations in public health that may affect scale-up are then discussed. Key
articles are reviewed and several public health examples illustrating different dimensions
of scaling-up are presented. The paper concludes with a discussion of what we do and do
not know about scaling-up in public health and a summary of proposed priority areas for
future research.
Background and Definitions:
There is an expanding literature examining how innovations can be made more
accessible to those who might benefit from them. In part, this is due to an increasing
recognition, that despite the development of innovative products, practices, and
programs, we have often fallen short of realizing their full potential impact, due to
scaling-up challenges (Mangham & Hanson, 2010). This paper considers scaling-up
issues that are pertinent to the field of public health, using literature that addresses public
health services in both developed and developing countries.
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Various definitions of scaling-up are found in the literature. Common elements
include a description of scaling-up as a series of processes to introduce innovations with
demonstrated effectiveness through a program delivery structure and with the aim of
improving coverage and equitable access to the innovation(s) (Mangham & Hanson,
2010). For example, a consensus conference in the field of rural development defined
scaling-up as, “efforts to bring more quality benefits to more people over a wider
geographical area more quickly, more equitably and more lastingly” (IIRR, 2000, p. iv).
In the health sector, scaling-up has been defined as, “efforts to increase the impact of
innovations successfully tested in pilot or experimental projects so as to benefit more
people and to foster policy and program development on a lasting basis” (Simmon,
Fajans, & Ghiron, 2008, p. viii). Similarly, Victora and colleagues. ( Victora, Hanson,
Bryce, & Vaughn, 2004b) defined going-to-scale as, “a policy that builds on one or more
interventions with known effectiveness and combines them into a programme delivery
strategy designed to reach high, sustained, and equitable coverage, at adequate levels of
quality, in all who need the interventions” (p. 1541). Their reference to a policy
underlying going-to-scale reflects an organizational or political intentionality to this
process. Finally, Mangham and Hanson (2010) highlighted the importance of
considering external contextual influences in planning a scaling-up approach. They
suggested that scaling-up be considered a process requiring “a strategy and
implementation plan that considers the policy context, delivery mechanisms and resource
requirements, as well as the pace of change, sequencing of activities, areas for
prioritization and monitoring and evaluation” (p. 87).
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Although approaches to scaling-up are arguably pertinent to a wide range of
public health innovations, those which have received prominence address problems that
are particularly impactful, complex and intransigent. For instance, public health issues
that have been addressed in the scaling-up literature include providing antiretroviral
medications (ARVs) for HIV-positive individuals (Bulterys, Vermund, Chen & Ou,
2009; Libamba, Makombe, Mhango, de Ascurra, Limbambala, Schouten, et al., 2006;
Lowrance, Makombe, Harries, Shiraishi, Hochgesang, Aberle-Grasse, et al., 2008;
Stringer, Zulu, Levy, Stringer, Mwango, et al 2006; Yin, Zhang, Juniper,& Wu, 2009),
tackling under-nutrition and childhood obesity (Policy brief, 2010), increasing access to
essential child health interventions (Stenberg, Johns, Scherpbier, & Edejer, 2007),
providing mental health services in primary care (Chisolm & Lund, 2007; Lancet Mental
Health Group, 2007; Mental Health Commission of Canada,, 2009), improving living
conditions for slum dwellers (Davis, 2007), and reducing homelessness (Nelson, Aubry
& Lafrance, 2007; Mental Health Report, Canada, 2009).
Features of Innovations for Scale-up:
Roger’s Diffusion Theory (1995) identifies several features of an innovation that
will influence its rate of diffusion within a population including its affordability,
compatibility, transferability and usability. There has been a great deal of research
confirming that these characteristics of innovations predict their rate of diffusion. Gericke
et al. (2005) described four dimensions of complex interventions that determine their
technical complexity and may influence their uptake. Similarly to Roger’s, they also
described characteristics of the intervention that affected diffusion, but noted that features
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of intervention delivery, government capacity requirements to deliver the intervention
and characteristics of use also affected rates of uptake. Despite a vast literature on
diffusion of innovation, there is no agreed upon typology for classifying innovations
according to their potential for scale-up. In this section, a potential typology of
innovations relevant to public health is put forward. Factors that appear to influence the
scale-up of each class of innovation are also discussed.
Discrete innovations:
The first class of innovations are those most commonly described in the scaling-up
literature. These innovations are discrete and well-defined and have been called direct
interventions (Policy Brief, 2010). They are considered ready for scale-up because of
demonstrated efficacy and effectiveness and they involve delivery mechanisms that may
at first glance seem rather straightforward. Vaccines, ARVs for HIV, micro-nutrient
fortification and fluoride in drinking water are examples of this class of innovations.
While there is much complexity in the science behind each of these innovations, the
innovation product is packaged for ease of delivery. However, as the public health
literature reminds us, even the delivery of these discrete interventions involves a complex
causal pathway that may not have been adequately examined through effectiveness trials
(Victora et al., 2004). Thus, effectiveness studies that do not address the complex
interface between innovations and the systems into which they are introduced may
overestimate the scaling-up potential of these innovations. In a discussion of research
designs to examine public health interventions, authors Victora, Habicht and Bryce
(2004a) have made a case for examining complex causal pathways through plausibility
and adequacy designs. They argued that these designs will enhance the internal and
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external validity of study findings. However, they called into question the assumption
that, “the intervention delivered through RCTs can be replicated under routine
conditions” (p. 400) in part, because many system pathways are essential for the
successful scaling-up of effective interventions such as childhood immunization.
The introduction of HPV vaccine is an example of a relatively recent innovation that
highlights these system pathways. For example, the acceptability of HPV vaccine among
the public and health providers has been affected by issues including: implications of
sexual activity among pre-teen and adolescent girls, delays in being able to demonstrate
vaccine impact due to the natural history of cervical cancer (particularly in contrast with
the natural history of many other infectious diseases), and concerns about the possibility
that young women who received HPV vaccine may decline regular pap screening if they
consider themselves protected against all forms of cervical cancer (Cates, Carpentier, &
Reiter et al, In Press; Chapman, Venkat, & Ko, et al, In Press; Ogilvie, Anderson, &
Marra, et al, 2010; Rouzier & Giordanella, In Press; Yeganeh, Curtis, & Kuo, 2010;
Gasparini, Amicizia, & Manfredi et al, 2009; Nohynek, 2008). Scaling-up HPV
immunization has required intense media campaigns directed at both parents and
teenagers, that address some of these concerns (Chapman et al., In Press). The
importance of health professionals providing credible and targeted information regarding
HPV has also been documented (Cates et al, In Press). The challenge of equitable
coverage has been identified - parents with higher incomes are more likely to get their
daughters immunized than parents with lower incomes. Political support for the
intervention has been sought, in order to include the vaccine in the suite of routine
childhood vaccines, thus ensuring ongoing delivery mechanisms and increasing
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accessibility. Thus, efforts have been directed towards improving the supply of the
vaccine while also increasing the demand for the vaccine.. This example points to the
many system pathways that are involved in scaling-up discrete interventions.
Multi-component and multi-level innovations:
A second class of innovations involves many interacting program elements (a
composite set of innovations) that are targeted at more than one system level. These
innovations are more complex, less prescriptive, less structured and have components
that must act synergistically to yield their intended benefits. Elements of these complex
innovations need to be adjusted to both characteristics of target populations and dynamic
implementation contexts while retaining the active and effective ingredients of the
intervention. Furthermore, some of these innovations may diffuse naturally, that is
without any planned programmatic interventions. This is the case, for example, when a
health issue is addressed through a social movement. The introduction of multicomponent programs such as those seen in the fields of tobacco control, heart health,
childhood obesity prevention, and workplace safety are illustrative of this class of
innovations.
The effective scale-up of these innovations is dependent not only on the
relationships and interactions among program elements but also on contextual influences
at all systems levels. For instance, factors such as organizational policies, legislation and
regulations, political support, levels of community engagement, leadership, demand for
services, accountability systems, and social networks have been shown to influence their
scale-up (Mangham & Hanson, 2010; Merzel & D’Afflitti, 2003; Policy Briefs, 2010;
Riley, Edwards & D’Avernas, 2007; Simmonds, 2008). Thus, with this class of
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innovation, there may be considerable blurring between what is the innovation and what
is the implementation context.
Congruent with the documented importance of contextual influences on the scaleup of these multi-component programs, authors are increasingly suggesting that
evaluation frameworks for these innovations reflect a realist approach that “enables
separation of the contexts, mechanisms and outcomes associated with a programme of
change” (McLean, Hoek, Buckley et al., p. 8). Finally, various authors have highlighted
the importance of a coherent approach to scaling-up this class of intervention, particularly
those involving multiple sectors (Geneau, Fraser, Legowski, & Stachenko, 2008; Policy
Brief, 2010). For instance, in a discussion of scaling-up multi-sectoral nutrition strategies
for young children and pregnant women, authors described the importance of the “Three
Ones” recommended by the European Commission “one agreed…framework that
provides the basis for co-ordinating the work of all partners; one national coordinating
authority, with a broad multisectoral mandate; and one agreed national monitoring and
evaluation system” (European Union, 2010).
Paradigmatic innovations:
The third class of innovations is paradigmatic. These innovations involve a shift in
the way we understand problems and needs, in what we consider to be viable solutions, in
who we think should be engaged in finding and implementing solutions, and in how we
attempt to engage them. Examples include applying a population health approach to
public health interventions with the primary aim of service delivery becoming a shift in
the distribution of risk within populations; using a determinants of health approach to
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address the causes of the causes in an upstream approach to programs; and introducing
health in all policies, as outlined in the recent Adelaide Statement (2010).
The latter example can be used to illustrate elements of this class of innovations and
what seems to affect their scale-up. The Adelaide Statement defines health in all policies
as an approach that “assists leaders and policy-makers to integrate considerations of
health, well-being and equity during the development, implementation and evaluation of
policies and services” (p. 2). As outlined in the statement and as described in a
comparative case study on intersectoral action (Geneau, Fraser, & Legowski et al, 2009),
scaling-up this kind of innovation requires several conditions. First a set of tools and
strategies are required including health impact analysis, platforms for partners to
coordinate their efforts, action teams that will provide leadership for cross-sectoral
efforts, and integrated budgets and accounting systems. Second, prior research reveals a
number of factors that increase the likelihood of scale-up success. These include, among
others, the engagement of stakeholders within and outside government, a clear mandate
for joining-up government efforts, along with partnerships and trust. Third, drivers of
this process are context-specific and include windows of opportunity for policy change,
strong alliances and partnerships that reflect mutual interests and shared targets,
government and administrative leadership at the highest levels (e.g. cabinet, parliament)
to advance the agenda, open and fully consultative processes, and feedback mechanisms
that allow monitoring of progress (Adelaide Statement, 2010).
It is apparent from this example of health in all policies, that this class of
paradigmatic innovation requires a systems-wide approach, and involves a complex set of
partnerships many of which may extend outside the typical domain of public health
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services. In some ways, these approaches to scale-up are similar to those outlined for the
second class of multi-component and multi-level innovations. However, central to this
third class of innovations is the fundamental paradigmatic shift that underlies the
innovation.
Factors Influencing Scale-up of Programs
An understanding of what can support the scale-up of programs comes from an
examination of both ineffectual and effective scaling-up. We begin with an examination
of less successful or thwarted efforts to scale-up innovation. Previous analyses of these
efforts provide some important insights on scaling-up challenges. These challenges can
be grouped into six categories: underestimating the resources required for scale-up;
political and policy naivety; lack of attention to issues of sustainability and scale-up
during early efforts to test or implement innovation uptake; an over-emphasis on either
the vertical or horizontal spread of innovations; inattention to spatial elements of scalingup; and, inattention to the demand side of scale-up. Each of these will be discussed in
turn.
Underestimating the type and quantity of resources required for scale-up:
The scale-up of innovative programs involves human, financial and infrastructural
resources. Examples of how these resource constraints have limited scaling-up
responses have been reported in many fields including mental health (Lancet Mental
Health Group, 2007), communicable disease control (Simmonds, 2008; WHO, 2006) and
the distribution of ARVs (WHO, 2007). Estimating the resources required for wide
scale-up requires more than a mere multiplication of resources needed for pilot programs.
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Relative to the pilot introduction of innovation, scaling-up may allow for per capita
savings due to economies of scale. However, the per capita cost of scale-up may be
increased when one takes into consideration the cost of reaching what Roger’s would call
the early adopters versus the late adopters of an innovation. This increase in costs is
particularly likely when issues of geographic access, poverty and other social
determinants such as illiteracy and regional deprivation magnify the effort and resources
required for the equitable scale-up of programs (Johns & Torres, 2005). Both the cost of
resources and the basket of resources required for these different sub-populations may be
considerably altered during scale-up. Estimating these costs across sub-populations,
geographic areas, and harder-to-reach target groups may be difficult.
Importantly, the absorption capacity needed for scale-up requires far more than health
human resources and strong leadership. Numerous authors have noted scale-up failures
that have resulted from either underestimating or ignoring system and absorption
capacities in other areas including governance, legal, administrative, supervisory,
accountability and financial systems (Adelaide Statement, 2010; Edwards & Roelofs,
2006; Gillespie, Karklins, Creanga, Khan & Cho, 2007; Hanson, Ranson, Oliveira-Cruz
& Mills, 2003; Huicho, Davila, Campos, Drasbek, Bryce & Victoria, 2005; Nyonator,
Woonor-Williams, Phillips, Jones, & Miller, 2005; World Health Organization, 2008).
Political and policy naivety:
Scaling-up requires political commitment and policy support. Several authors point
to failures to understand the actors involved in successfully scaling-up; and the
underlying dimensions of power, authority and vested interests that may adversely impact
on scale-up efforts. Policy is socially constructed, and policy actors differ in their values
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and interests and in their views about the content and goals of policy (Shiffman & Smith,
2007). As an example, in their discussion of barriers to scaling-up, the Lancet Mental
Health Group (2007) highlighted the absence of mental health from the public-health
priority agenda, which in turn has minimized commitments to financing, led to major
weaknesses in capacity for mental health reform, created centralized mental health
services with weak links between community mental health and general health services,
and resulted in a lack of agreed upon core measures of mental health services. In their
recommendations, they called first and foremost for “political will and solidarity…to
translate evidence into action” (p. 87).
Gilson and Schneider (2009) discussed the intersection of scale-up and
sustainability, noting that in order to achieve scale-up, one must basically “stay the
course.” This means a longer-term commitment not only to initial scale-up efforts but
also to sustainability requirements. They described the importance of actively creating
political commitment through advocacy and using alliances once the seriousness and
magnitude of the issue and its consequences have been documented. They also
differentiated between the types of management skills that are required for initial scale-up
processes (skills such as priority setting, identifying objectives, and rationalizing
resources) versus sustaining scale-up (skills such as “management flexibility and strategic
flair” (Gilson & Schneider, 2009).
Lack of attention to issues of sustainability and scaling-up in initial efforts to test the
innovation:
There is a growing consensus that conditions for sustainability and scale-up should be
considered early on in the process of introducing an innovation (Pluye, Potvin & Denis,
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2004). But too often these conditions are not taken into account until the post-pilot
project phase. Scaling-up strategies that are pertinent to earlier project phases include
appraising institutional capacity for scaling-up, and developing networks and partnerships
that reflect pathways to scaling-up from the grassroots to end users (Gundel, Hancock &
Anderson, 2001). When there is insufficient attention paid to scaling-up at the outset of a
program, key opportunities for organizational learning about ways in which the
innovation may need to be adapted for wider scale-up will be lost. Furthermore, early
inattention to scale-up may lead to the development of “boutique” interventions that are
not readily brought to scale.
Over-emphasis on either the vertical or horizontal spread of innovations:
An over-emphasis on either horizontal or vertical elements of scaling-up has also
proven problematic. Horizontal scale-up refers to the uptake of an intervention at the
same level of the system but across departments, organizations and/or sectors. It is
sometimes described as an integrated approach. An example is getting all front-line
providers including social workers, nurses, dentists and physicians working in acute care,
long-term care and community health sectors to assess all clients for their smoking status,
and offering brief interventions for those identified as smokers or recent quitters.
Vertical scale-up requires linkages among system levels so that a program with a specific
focus can be delivered. For instance, increasing the uptake of vaccines at the primary
health care level, involves a supply chain for vaccines that gets a quality product (i.e.
efficacious vaccine with potency maintained by a functional cold chain) from the
manufacturer to the client in the right dose and at the right time. Vertical programs are
often disease specific and centrally managed in isolation from general health services
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(Mangham & Hanson, 2009). In a review of case studies of effective large-scale
programs (Levine et al., 2004; Medlin et al., 2006), technical innovation, realistic
financing arrangements, effective management and strong leadership were all identified
as reasons for success. However, vertical programs have come under substantial
criticism because they are not well integrated within health systems. In a call for
“diagonal programs”, Ooms, Damme, Baker et al., (2008), noted that “a vertical approach
works for a while, and then hits the ceiling of insufficient health workers and
dysfunctional health systems” citing the example of AIDS treatment in resource poor
settings. In their recent systematic review, Atun, de Jongh, Secci et al., (2010) noted that
the level of integration within programs is very heterogeneous and while programs may
be more strongly vertically or horizontally integrated, they often include elements of
both.
In an example of over-emphasis on vertical scale-up, the scaling-up of ARVs for
people living with HIV/AIDS in lower income countries was planned without adequately
considering acutely limited health human resource capacity and consequently how these
vertically-driven ARV programs might horizontally distort the delivery of other health
services (Koenig, Leandre & Farmer, 2004; Libanba, Makombe, Harries, Chimzizi,
Salaniponi, Schouten et al., 2005). A vertical approach to HIV/AIDS interventions also
resulted in a lack of integration with other programs including those in sexual and
reproductive health, maternal and child health and other communicable diseases (Ooms,
Damme, Baker et al., 2008). An example of a scaling-up failure resulting from a focus
on horizontal scaling-up and inattention to vertical scale-up was the introduction of nurse
practitioner programs in Canada in the 1970s. Despite, substantial research evidence
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indicating the cost-effectiveness of nurse practitioners (NPs) in primary care, education
programs for NPs closed in the 1980s. In Canada, it was not until the 1990s that the
vertical regulatory structures and financing structures that were required to support the
long-term implementation of NPs in the health care system were finally addressed.
Inattention to spatial dimensions of scaling-up:
Both temporal and spatial dimensions of scaling-up are pertinent. However, the
public health and health services literature has concentrated on the spatial axis with a
focus on coverage, reach, availability and accessibility of services (Bryce, Victora &
Habicht, 2004; Glasgow, Klesges, Dzewaltowski et al., 2006; Mangham & Hanson,
2010; Murray & Evans, 2003; Verma, Shekhar, Khobragade, Adhikary, George, &
Ramesh, et al.2010). Indicators to assess these spatial attributes are in common use. The
temporal axis for scaling-up takes into account the differential rate of change at each
level of the system and the conditions that are required to initiate, sustain or alter change
processes both within and between system levels (Gunderson & Holling, 2002). This
temporal dimension is an inherent characteristic of complex adaptive systems, explaining
the adaptive processes of revolt (representing a systems change) and remembering
(representing a tendency to revert back to the status quo) that describe how innovations
take hold within and across system levels (Gunderson & Holling, 2002). Inter-system
fluidity for adaptive change is created through social capital and connectedness between
systems levels. For instance, inter-organizational networks and strategic alliances among
coalitions and advocacy groups may strengthen vertical connections, providing the intersystem social matrix that is required for scale-up (De Souza, 2008; Gallardo, Goldberg, &
Randhawa, 2006; IIRR, 2000). In contrast, inter-system rigidity is characterized by
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historical and contemporary power hierarchies that tend to reinforce the status quo. For
example, existing legal structures and social norms may reinforce discrimination and
stigmatization of population sub groups at whom new programs are aimed. Factors that
produce inter-system rigidity may overwhelm efforts to vertically scale-up an innovation
and create a tendency for a system to revert back to its former state. Thus, without efforts
to address the factors that tend to perpetuate the status quo (i.e. factors that reinforce
inter-system rigidity), the introduction of new innovations may fail in the long-run, even
if initial improvements are seen.
Inattention to the demand side of scale-up:
Tackling the supply side of scale-up involves putting in place strategies to make
the innovation readily accessible to targeted populations. The demand side of scale-up
refers to building demand ad expectations for the innovation among the targeted
populations. Pokhrel (2006) and others (Ensor & Cooper, 2004) have posited that we
have paid more attention to the supply side than the demand side of scaling-up,
reminding us that both are essential for sustained results. Furthermore, when the supply
side is weak, uneven or erratic, this may further reduce demand for the innovation.
Intermediaries can play a pivotal role in shifting demand as has been seen for example
with the media when it has successfully decreased the demand for vaccine through its
coverage of reported serious side effects or increased the demand for immunization
through reports of deaths of healthy children or adults resulting from disease. Strategies
for orchestrating the best quotients of supply and demand may be undertaken not only by
public health agencies but also by other sectors including those working with different
aims (e.g. tobacco industry).
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Scenarios:
In this section, several public health scenarios are presented and key elements described.
An example of each type of innovation outlined above is presented. Successes and
challenges in scale-up are identified, and scenarios are used to highlight some of the
attributes of scale-up presented above. Finally, illustrative research questions are
described following a discussion of each scenario.
H1N1 immunization:
The H1N1 pandemic of 2009 highlights several important elements of scaling-up
that are pertinent to discrete innovations. Scaling-up issues that arose during the
epidemic included how to prepare for a range of potential scenarios that might
characterize the epidemic scenario, how to deploy an ethical and cost-effective approach
to the distribution of a limited resource (vaccine and Tamiflu), how to use the media as a
critical strategy for increasing the demand side required for scale-up, and how to continue
with essential services when public health workers across Canada were being redeployed
to manage the outbreak. .
A recently released report by the Chief Medical Officer of Health for Ontario
(Canada’s largest province) reveals important insights into the challenges of scaling-up.
In this report entitled “The H1N1 Pandemic – How Ontario Fared” (King, 2010), several
factors, critical to Ontario’s positive/successful response to the epidemic, were described.
These included timely communication with the media and the public; implementation of
a coordinated surge capacity management plan by the province’s Critical Care
Secretariat; opening 60 flu assessment centres in the province to reduce the burden on
other parts of the system such as emergency rooms; the availability of a stockpile of
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Tamiflu; and establishing priority groups for the vaccine including pregnant women,
children age 6 months to 5 years and those living in remote and isolated communities
(King, 2010). In describing what went right in the response to H1N1, Dr. King
highlighted collaborative efforts (global to local) with a common commitment to reduce
the impact of H1N1, keeping schools open and having a management plan for vaccine
delivery in remote northern communities.
The challenges encountered during the epidemic included a disconnect between
the supply of and demand for vaccine. This was exacerbated by some delays in the
distribution of vaccine because it was decided that pregnant women should be given
unadjuvanted vaccine while the rest of the population was to be given adjuvanted
vaccine. Vaccines were packaged in doses of 500, complicating distribution to small
clinics and family physician offices, and a huge upswing in public demand for vaccine
followed media reports of two healthy children who died from H1N1. Finally, a lack of
electronic medical records and pan-provincial electronic systems to track immunization
meant that nobody was able to accurately monitor whether or not specific target groups
were receiving the vaccine. The report concluded with a discussion of improvements
required. One of these is particularly germaine to this paper – “The ingredients for a first
class system are there, but they need to be better integrated and coordinated to make it
function more as a system in a pandemic or any other health emergency, when what is
needed more than anything else is just that: a system.” (King, 2010, p. 17). This
observation of the importance of a systems approach to scale-up is consistent with
emerging calls for strengthening the system components of health care systems (WHO,
2009) in scaling-up efforts.
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Key research questions arising:
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 scale-up?
What are the most effective strategies for simultaneously strengthening supply of and
demand for an innovation and how can these be managed within the public health sector
and with other sectors and intermediaries?
Tobacco Control:
Addressing tobacco use in North America has required ongoing efforts to scale-up
tobacco control programs. These programs involve the use of multi-component strategies
involving long-term efforts to scale-up innovations through all system levels (from
individual to global). A number of key learnings related to scale-up emerge from this 40
year history of tobacco control efforts. First, as shown in many jurisdictions, government
commitment at municipal, provincial/state and federal levels has been essential to
resource a comprehensive tobacco control strategy involving multi-faceted interventions
over an extended period of time (Pierce, 2007). Second, the work of coalitions and
alliances has been critical to maintain momentum towards tobacco reduction goals, and to
direct media and public attention towards changes, such as reductions in tobacco tax, that
would have weakened key strategy elements. These alliances have helped to build a
ground-swell of support from the public for stronger tobacco control measures and
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enhanced recognition of that public support among politicians working at municipal,
provincial/state and federal levels. Alliance members have also worked across political
jurisdictions, using a systems approach to address tobacco control (Davis, Wakefield,
Amos & Gupta, 2007). Furthermore, they have addressed the temporal dimensions of
scale-up providing continuity and momentum for a social movement on tobacco control
that transcends borders and spans changes in political leadership. Third, monitoring and
evaluation systems had to be put in place to inform decisions about steady or failing
progress in tobacco control. These systems used some nationally and internationally
agreed upon indicators; provided data on a wide range of short-term, intermediate and
longer-term outcomes that helped identify shifts in patterns of tobacco use signalling
scaling-up successes and challenges. For instance, increases in smoking rates among
adolescent females, and shifts from cigarette to smokeless tobacco use (Morrison,
Krugman & Park, 2008) provided the basis for adjustments to tobacco control programs.
Fourth, comparative epidemiological and policy analyses have provided a means to
examine the most salient elements of policy strategies and the differential impact of these
policy elements on population sub-groups.
Throughout this period of tobacco control efforts, constant vigilance has been
required to identify counter measures by the tobacco industry, including shifting
marketing strategies to target youth, cross-border advertising, and strategic efforts to
delay and weaken the content and scope of legislation (Assuntha & Chapman, 2004;
Landman & Glantz, 2009; Mackenzie, Collin, & Sriwongcharoen, 2007; Nakkash & Lee,
2009; Pierce, Messer, James, White, Kealey, & Vallone, et al, 2010). These counter
measures by the tobacco industry represent efforts to descale tobacco control programs
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while scaling-up market share of tobacco products. Finally, with ratification of the
International Framework on Tobacco Control new opportunities for examining scale-up
at international levels have emerged (Fong, Cummings & Shotland, 2006).
Key research questions arising:
What can be learned about successful efforts to scale-up the adoption of unhealthy
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?
What are the global and international mechanisms required to support scale up?
Policy change and built environment
The built environment has many direct and indirect influences on health. It has been
implicated in relation to indoor air pollution and lung disease, falls and injuries, the
walkability of communities and patterns of physical activity (Edwards & Kelley, in
press). The built environment offers an interesting set of scale-up challenges because of
its enduring features; the omnipresent influence of the built environment on many human
activities; and the role of other sectors in planning, designing and constructing the built
environment. Decisions about land use, public and private building construction and
transportation networks all have long-term and direct influences on health as well as a
steering effect on future options for the built environment. As an example of direct
influences, the type of insulation permitted in housing or the geometry of stair
construction can expose or protect populations to/from hazards for decades. The longterm steering effect of decisions about the built environment is being seen through North
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America’s transportation networks, which have favoured private automobile travel as a
means of transportation. These transportation networks influence decisions about land
use (suburban sprawl, transportation corridors for diesel trucks) and public transportation
(low density populations in suburbs that do not make public transportation economically
viable, construction of roads being prioritized over construction of walking and bike
paths).
The cumulative effects of the built environment on the health of populations and
on health disparities, and the ways in which current decisions about the built environment
may influence the introduction and scale-up of future innovations need to be better
understood. The built environment provides a compelling example of the historical and
structural influences on health inequities that persist as scaling-up influences on
contemporary public health interventions.
Key research questions arising:
How are scaling-up experiences initiated, led and managed over time? (Gilson &
Schneider, 2009)
Does long-term modeling of the projected impact of scaling-up regulatory influences on
the built environment shift decision-making about options for land use, urban design,
transportation corridors or housing developments?
How does the scale-up of features of the built environment influence short-term versus
long-term mitigation or exacerbation of health disparities?
Summary:
In this paper, several types of public health innovations have been considered, each with
characteristics that impact on their scalability. The three types of innovations outlined in
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this review were discrete innovations, innovations that are multi-component and multilevel, and paradigmatic innovations. In this final section, a summary of what we do and
do not know about scaling-up these types of public health innovations is presented.
What we know about scaling-up:

Scaling-up involves a complex chain of program mechanisms even for discrete
innovations. Many factors external to the innovation itself influence scale-up
including: system adsorption capacity, governance mechanisms, partnerships,
political will, leadership, and financial accountability structures.

Scaling-up public health innovations is not a linear process. Rather it involves
adaptive changes to the innovation and to the program mechanisms for scale-up
so that they better reflect the social and political milieu. Understanding and
adapting innovations to the dynamic context for their scale-up is essential to
success.

Health issues requiring an immediate and rapid response appear to involve similar
considerations for scale-up as health issues requiring a longer-term response.
However, in a crisis situation, there may be a period of political will, and
readiness to work in a more integrated way and to introduce systems that enhance
scale-up processes. Thus, 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.

A long-term view of scaling-up is required because of the tendency of a complex
adaptive system to revert to status quo and because of the enduring influences of
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some changes (e.g. built environment exerts structural influences on health and
health-related decisions for years). A long-term view is also important because
differing sectoral or private interests (e.g. private industry) may thwart scale-up
efforts in public health (as has been demonstrated in the field of tobacco control).

Both horizontal and vertical dimensions of scaling-up are important, even when
an innovation would appear to primarily require a vertical approach for delivery
(e.g. vaccine delivery).
What we don’t know about scale-up:
The state of the science on scaling-up in public health is characterized by numerous gaps.
Some of these are described below.

Systematic inquires of scaling-up in public health have been concentrated on
vertically delivered programs involving discrete interventions, particularly in the
field of international development (Mangham & Hanson, 2010; Medlin et al.,
2006). However, there is evidence of the successful scale-up of public health
programs, such as those in the field of tobacco control, injury prevention and
heart health for which substantial gains in the health of populations have been
documented in some countries. Although studies of scaling-up are limited, a
composite set of studies describing efforts to address these health issues may
yield further learning about scale-up. Case studies, such as those used to examine
inter-sectoral collaboration (Geneau, et al., 2009) suggest some new directions
for assembling the evidence on scale-up.

Although equity dimensions of scale-up have been described, equity analyses
needs to be more fully incorporated in scale-up studies. Additionally, approaches
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to scale-up that optimally strengthen equity, while improving overall health status,
need to be examined.

Although there have been a number of efforts to estimate the costs of scaling-up
public health interventions such as childhood disease prevention, mental health
and nutrition interventions, there remain many gaps. Johns & Torres (2005) have
called for a more thorough and rigorous set of methods to be used for costing.
Procedures for estimating indirect costs (e.g. cost of lay health workers in chronic
disease or maternal and child health programs) also require attention. More
consistency in the costing methods used across settings would more readily
permit comparisons across scaling-up approaches.

Little is known about what is required for initial versus sustained scale-up. This
is an important area of future inquiry. There is also a need for more cross-over
learning between studies of sustainability and scale-up.

Research is needed on different approaches to scaling up-across classes of
innovations and their comparative effectiveness under a range of contextual
conditions (governance, financing, leadership, political support).
Recommendations for Future Research:
In this final section, several research recommendations are outlined. These are
complementary to the knowledge gaps identified in the previous section.

A typology for classes of innovation in public health warrants further
development. Those presented in this working paper may provide a starting point.
Further discussion is required regarding the types of evidence that are needed to
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support scaling-up decisions, beyond evidence on efficacy, effectiveness and costeffectiveness for discrete interventions.

A stronger evidence base is needed to determine which discrete and multicomponent innovations are ready to go-to-scale and which are not. The
characteristics of scalable interventions need to be better defined.

A framework needs to be developed for the contextual analysis of scale-up. This
would provide the basis for more thorough comparisons across studies of different
health issues. Factors that should be considered for inclusion in the framework
are organizational policies, legislation and regulations, political support, levels of
community engagement, leadership, demand for services, accountability systems,
and social networks.

Better research designs and more variability in these designs are required to
appropriately answer questions about scale-up. For example, a more thorough
examination of scale-up will require using plausibility and adequacy designs in
studies of effectiveness and using comparative case studies to provide an in-depth
analysis of scaling-up processes and conditions for scaling-up.

Scaling-up research on public health innovations should include equity outcomes.
Research is needed to identify mechanisms for scale-up that increase the
likelihood of achieving equity in the accessibility, affordability and acceptability
of innovations. In addition studies are required to examine how public health
innovations that are scaled-up simultaneously or in sequence impact on equity
outcomes. For example how do efforts to improve equitable access to vertically
scaled-up public health programs shift access to other programs and how can
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coverage and equity aims of scale-up be balanced given resource constraints?
(Mangham & Hanson, 2010)

There are a number of temporal dimensions to scaling-up that warrant further
study. These include examining how scale-up occurs between system levels,
studying the how the role of social movements and alliances in scaling-up
processes shift over time, and examining what conditions are needed for initial
scale-up versus sustained scale-up under different contextual conditions.It would
be useful to identify what monitoring and feedback systems are needed to better
capture scaling-up processes so that these can be integrated into the planned scaleup of large initiatives. A research agenda on scale-up requires the application of
science from the fields of complex adaptive systems, systems redesign,
complexity science, and from other related disciplines. De-scaling is another
interesting dimension of scale-up. There has been a major focus on what should
be introduced into public health systems and how it can be added to what is often
already a full set of responsibilities. De-scaling, the question of how to remove
interventions that have already gone to scale warrants more attention.
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