W O R K S H O P B R I E F I N G 2 • J U L Y 2 0 1 0

Beyond Scaling Up: Pathways to Universal Access Experiences with Large Scale Health Interventions

We face a rapidly changing global context: new and emerging challenges including the HIV epidemic, global pandemics, complex health markets and the increasing influence of emerging economies require different responses. There are new and emerging opportunities, with new ways of facilitating rapid learning.

There are no ‘magic bullets’: narrowly technical approaches to transforming health systems rarely work.

Health systems professionals have much to learn from other sectors: health is affected by systems outside of the narrowly defined health sector, it is important to be in dialogue with those thinking about change in other sectors as well as engaged with the wider socioeconomic and policy context.

Challenges of implementation are often neglected by current frameworks: many new andpotentially effective interventions fail because of problems in implemen-tation. While it may be possible to replicate the effects of a new drug, it is difficult to transfer institutional arrangements between contexts. We need to build management capacity and systems.

Scaling up is a social and political process as well as a technical process: introducing new practices or technologies on a large scale requires institution-building and attention to local realities and power structures.

Local adaptation to local contexts; global goals need to be tailored

for local realities: this is dependent on local capacity, leadership and institutions, and also on the path dependency of these institutions.

The institutional mechanisms around the delivery of a new technology are as important as the technology itself: local innovation and institution building must be supported.

We need continuous learning and feedback mechanisms in order to ensure ongoing adaptation to dynamic contexts: an important part these concerns is the engagement and input of local service users themselves.

We need to prepare for uncertainty: scaling up plans need to accom-modate emergent behaviours and unintended consequences.

Key ideas

Frameworks for understanding and managing large scale changeContextualising scaling up: lessons from ExpandNetRuth Simmons, University of Michigan School of Public HealthNew interventions must be tested in context before being expanded and institutionalised, or ‘scaled up’

The ExpandNet ‘pilots to programmes’ model emerged in response to repeated failures in attempts to introduce

new contraceptive technologies into family planning programmes, usually because of inadequate delivery structures and poor understanding of the wider socio-economic and political context. Context is placed at the centre of the ExpandNet scaling up framework, and technology is understood as only one element alongside broader organisational structures and processes. The model aims to provide ‘proof of implementation’ as well as proof of technological concept.

ExpandNet has developed a framework and tools for scaling up which emphasise the importance of assessing how the health system actually functions and encourage participatory approaches. An important lesson has been the need to consider the feasibility and costs (technical, human and financial) of scale up in the design of pilots.

Useful links

View Simmons’ presentation from the workshop http://ww.slideshare.net/katecommsids/simmons-expand-net

Practical Guidance for Scaling Up Health Service Innovations http://www.expandnet.net/PDFs/WHO_ExpandNet_Practical_Guide_published.pdf

Scaling Up Health Service Delivery: From Pilot Innovations to Policies and Programmes http://www.expandnet.net/volume.htm

Nine Steps for Developing a Scaling Up Strategy http://www.expandnet.net/PDFs/ExpandNet-WHO%20Nine%20Steps%20for%20Strategy%20Development%2011-10-09.pdf

This briefing is part of a series from a workshop held at the Institute of Development Studies in May 2010. The workshop was co-sponsored by the STEPS Centre and the Future Health Systems Consortium. The objectives of the workshop were to:

•• Explore approaches that have fostered innovation, rapid learning and large scale impact in the health sector that incorporate context and social arrangements as central to learning and change

•• Identify practical approaches for collaboration between innovators, researchers, governments and funding agencies to strengthen the capacity of health systems to meet the needs of the poor

The briefings provide summaries of the presentations that were given and key issues and concepts that were raised by participants.

Beyond Scaling Up: Pathways to Universal Access W O R K S H O P B R I E F I N G 2 • J U L Y 2 0 1 0

What has the ‘markets for the poor’ (M4P) approach learned about the implementation of large scale change?Alan Gibson, Springfield Centre

Constraints in the whole complex system affecting the health of the poor should be identified and addressed

The M4P systems approach has developed in response to the failure of conventional development approaches which tend to over-emphasise narrow supply side and service delivery interventions, and out of concern for the lack of interaction between development practitioners working in different fields. The approach rejects the isolated, project-based practices of much development and seeks to take into account the entire system surrounding the poor. The market systems framework emphasises the importance of engaging with wider socio-economic and policy factors, broadly grouping these as ‘supporting functions’, for example infor-mation systems and related services, and ‘rules’, which include governance systems, laws and informal norms. The first stage of a market systems approach is to identify what is going wrong in the system. What are the underlying problems and constraints that prevent the achievement of desired outcomes (such as, for example, access to a new healthcare technology)? Interventions focus on addressing constraints rather than introducing new or alternative supply-side measures.

The market systems approach embraces a pluralistic vision of systems; many sectors affect health and influence how people access and interact with health services and it is important to engage with these different actors. A market systems approach to scaling up a new health intervention builds on thorough analysis of the entire context in order to identify and address potential obstacles to change. These become the focus of intervention design.

Useful links

View Gibson’s presentation from the workshop http://www.slideshare.net/katecommsids/beyond-scaling-up- making-markets-work-for-the-poor

Resources on the M4P approach http://www.sdc-employment-income.ch/en/Home/Making_Markets_Work_for_the_Poor/Resources_on_the_M4P_approach

Increasing poor people’s access to financial services in South AfricaIn South Africa it was found that the underlying causes of poor people’s lack of access to financial services were poor coordination, weak information services, informal and formal irregularities and a lack of incentives. Rather than introducing new, parallel interventions for the poor such as micro-credit schemes, policy makers focused on better coordination and information mechanisms; access to financial services among the poor increased from 38 to 60 per cent.

Increasing productivity among small farmers in BangladeshIn Bangladesh the low productivity of small farmers was found to be because they sought farming advice from retailers, who did not always have accurate information. Retailers were trained to give good advice and farmers’ yields increased by one third.

Health worker shortages in Bangladesh Inappropriate rules on curricula, entry criteria and performance were found to be the underlying causes of health worker shortages; policy makers have worked to adjust these rather than spending funds on NGOs training up new health workers.

Market Systems Approach in Practice

What is social innovation?Charles Gardner, Global Forum for Health Research

Social and technological innovation are two sides of the same coin

Charles Gardner’s presentation highlighted the need to encourage local social innovation. Until quite recently in global health, innovation was most closely associated with patents, profits and the high cost of medicine. Now we are more comfortable talking about the need for innovation in products to address the health needs of developing countries, and innovation to deliver those products to the people who need them. We are less familiar, however, with the concept of “social innovation,” which involves new ways to manage people, finances and information in the systems that affect health, including better ways to deliver products and services. Comparing and contrasting technological and social innovation may bring new insights.

Over the past decade a variety of “push” and “pull” incentives have been proposed or implemented to promote technological innovation for global health. Billions of dollars have been committed to push incentives including research grants, public-private product development partnerships and tax breaks for R&D, and to pull incentives such as advance market commitments, market analyses, priority review vouchers and prizes. But what are the push and pull incentives for social innovation? Why is no one talking about prizes for social innovation, and why has the global health community paid so little attention to the field of social entrepreneurship? (Both cases highlight the importance of Ashoka and the Schwab and Skoll Foundations which collectively recognise, applaud, network and support social entrepreneurs.)

In later discussion, Dr. Gardner stated: If all we do is look for best practices to scale up, then we have probably missed the boat because social innovation is so context specific; what works well in one setting may work less well in another, or not at all. One gets the false impression that all we need is more money, doctors and nurses to solve all the problems in global health. Instead, we should focus on how to create more conducive policy environments for local experimentation to continually improve how we manage those doctors and nurses, and existing finances.

Useful links

View Gardner’s presentation from the workshop http://www.slideshare.net/katecommsids/gardner-social-innovation

Ashoka http://www.ashoka.org/

Schwab Foundation for Social Entrepreneurship http://www.schwabfound.org/sf/AboutUs/index.htm

Skoll Foundation http://www.skollfoundation.org/

Beyond Scaling Up: Pathways to Universal Access W O R K S H O P B R I E F I N G 2 • J U L Y 2 0 1 0

Lessons from case studiesTaking innovation to scale in Northern Nigeria: reconciling global goals and local interestsJeff Mecaskey, Health Partners International

Efforts to improve child and maternal health in northern Nigeria illustrate the challenges of reconciling global goals and narratives with local realities and interests. The Partnership for Reviving Routine Immunisation in Northern Nigeria (PRRINN) and the Maternal Newborn and Child Health Initiative (MNCHI)were developed in the context of the International Health Partnership (IHP). The IHP encourages donor countries and other development partners to coalesce around a single country-led national health strategy, guided by the principles of the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. The northern Nigerian context presents a number of challenges. Health-wise there is extremely high maternal and infant mortality, and high levels of malaria, which was people’s primary health concern. In addition public sector institutions are poorly developed and governed and there are different political processes and interest groups in different regions.

The programme implementers recognised that interna-tionally-instigated health system reform measures entail a significant transfer and allocation of resources and are therefore a profoundly political process. An important part of the programme’s work was therefore around under-standing and building on different interests, and in particular identifying which interests might be drivers for change in northern Nigeria. In addition to looking at outcomes, the programme also looks at system-wide processes focusing on operations research, strengthening governance and health management, improving fiscal accountability, encouraging a shift from a patronage to knowledge culture and creating demand. Early results reflecting successes – such as the doubling of routine immunisation rates in the intervention areas – were used to garner support and create consensus.

The Nigerian case illustrates that the health system is a social institution rather than the aggregation of technical inputs, and that local interests and specific context shape the application of global health narratives and goals.

Useful links

View Mecaskey’s presentation from the workshop http://www.slideshare.net/katecommsids/beyond-scaling-up- prrinn-in-nigeria

Malaria Consortium: lessons from rapid expansion of malaria programmesSunil Mehra, The Malaria Consortium

Sunil Mehra’s presentation reflected on the strategies used by the Malaria Consortium to achieve universal access to Long-Lasting Insecticidal Nets (LLIN), looking at evidence from Uganda, Nigeria, Mozambique and other African countries. They have adopted an approach which engages with the public and private sectors as well as civil society. All three sectors have different comparative advantages in

different settings; the public sector can improve health services and offer stewardship, civil society focuses on ensuring the most marginalised groups have access and the commercial sector can improve access through competition.

The consortium’s experience has shown that free public campaigns rapidly increase coverage, but that when scaling up these interventions long term thinking is necessary.

Mosquito net use and coverage declines much more rapidly than anticipated and can be down to 50% within two or three years, so there is a need to integrate replacement strat-egies into the programme from the outset. It is important to sustain high coverage through routine free distribution at ANC and health facilities and by ensuring access to affordable LLINs in the commercial sector. The private sector can assist with continuous distribution of mosquito nets, particularly as they often have mechanisms in place already to reach wider markets. To fully realise the public health impact of large investments in malaria there is a need to maintain ‘universal’ coverage for long periods; this is only possible through mixed models of delivery. Over time as transmission declines from use of effective preventive inter-ventions there will also be a need to move from global standard approaches towards local solutions to sustain gains and achieve the goal of elimination.

Mehra posed a number of questions around how international agencies and donors frame malaria prevention; what is meant by universal access? What about the seasonality and different levels of vulnerability to Malaria? How does one deal with donors who want to shift the focus of their intervention half way through?

Useful links

View Mehra’s presentation from the workshop http://www.slideshare.net/katecommsids/mehra-malaria-consortium

Link to the Malaria Consortium website http://www.malariaconsortium.org/

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Discussions following the presentation touched on the need to acknowledge and take into account the different patterns of risk for diseases such as Malaria, and asked how these and other axes of diversity and change were anticipated. Mehra responded that the team meet once every three months to stay abreast of the changing context. Other partici-pants reiterated the importance of political processes and local interests as potential obstacles to interventions, particularly in contexts like Nigeria.

Another set of comments expressed concern at the lack of connection to the pre-existing liter-ature in development; is concern with context and complexity new? Simmons responded that the ExpandNet strategic approach looks at actual service delivery, which has been neglected in the past. To do this the group have developed a new participatory tool to understand context and service user experi-ences. Mecaskey added that while in some ways presenters were re-raising issues

discussed 25 years ago, everything then was focused on medical technology; it is new to think about systems development rather than technological development. Other participants emphasised that the changing context made it important to revisit and rethink ideas. Gibson pointed out that donor practices were changing, and that while currently governments are at the heart of the health system, it is important to think about how health systems might look in the future. Other participants emphasised the importance of continuously challenging the orthodoxies and staying alert and aware of what is happening now, and the new opportunities opening up.

Another theme that was brought up by partici-pants was concern for donor investments and time frames. The approaches discussed by presenters all require long term investment from donors.

Beyond Scaling Up: Pathways to Universal Access W O R K S H O P B R I E F I N G 2 • J U L Y 2 0 1 0

This briefing was prepared by Peroline Ainsworth andKate Hawkins on behalf ofthe Future Health Systems Consortium.

The authors express their appreciation for the financial support (Grant # H050474) provided by the UK Department for International Development (DFID) for the Future Health Systems Research Programme Consortium. This document is an output from a project funded by DFID for the benefit of developing countries. The views expressed are not necessarily those of DFID.

The STEPS Centre is a collaboration between the Institute of Development Studies and SPRU Science and Technology Policy Research at the University of Sussex with a network of partners in Asia, Africa and Latin America and is funded by the Economic and Social Research Council. The Economic and Social Research Council is the UK’s largest organisation for funding research on economic and social issues.

Session discussion