Operating at scale in public health: Lessons and limitations of the current literature

Objective Recent advances in global health have highlighted the challenge of “scaling up” effective interventions and delivery models to improve the health of larger populations. Research is now leading to greater systematic understanding of scaling up, and raising a set of “next generation” questions about sustaining operations at scale over time. Our literature review attempts to distill key components of successful scale up, apply them to operations at scale, and determine what is needed to sustain scaled global health programs. Data Our review incorporates existing academic and grey literature on scaling up, drawing heavily from a number of conceptual frameworks. We utilize publicly-available research and reports on programs operating at scale. Methods We conducted literature searches on “scaling up” and “operating at scale” using online databases (PubMed, etc). A synthesis framework, incorporating key components of successful scale up identified in existing frameworks, was developed and applied to a number of programs operating at scale in order to test its applicability. Results Existing scaling up literature offers useful but limited understanding of strategies associated with success or failure in operating at scale. Successfully sustaining scale requires focusing on what some have called program “depth” – not only geographic coverage, but system resources, political buy-in, supportive community relationships and other components to root the program durably in its environment. Policy Implications Components identified as necessary for sustained operation at scale should be incorporated into programmatic M&E requirements, and must be a focus of donors' efforts in establishing and expanding global health programs.