Understanding scale-up: Research and programmatic challenges

To achieve the Millennium Development Goals, scale-up efforts must be multiplied several times over. However, serious gaps exist in understanding the processes by which innovations are implemented and sustained. A five-year prospective, multi-site comparative study of the process and outcomes of scaling up a family planning innovation, the Standard Days Method, is underway in Mali, India, Madagascar, Guatemala and Rwanda, drawing upon the ExpandNet/WHO scale up model. Data collection includes service statistics, household surveys, facility assessments, in-depth provider/stakeholder interviews, most-significant-change stories and process tracking. The ExpandNet model grounded development of a feasible yet rigorous methodology, and facilitated operationalization of the scale-up concept. Data from the first year of research suggest that assessment prior to engaging in scale up and throughout the process is critical to identify needed adjustments, maintain momentum and accountability and build strategic planning skills among stakeholders. Analysis of the innovation, resource team, scale-up strategy, environment and user organizations resulted in redefinition of the innovation to include not only the technology (Standard Days Method) but also supporting values such as male involvement and informed choice, as well as interventions required to make the technology available. Lessons learned will be discussed, including: adapting research methods to a rapidly shifting environment, involving multiple partners in the research, balancing competing programmatic and research needs, and producing relevant, timely data for stakeholders with diverse needs. Methodological issues such as indicator selection, use of a comparative study design, and controlling the pro-innovation bias of researchers will be discussed.