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Table 3 Existing frameworks, checklists and tools used for scaling up health interventions and scalability assessment

From: Intervention Scalability Assessment Tool: A decision support tool for health policy makers and implementers

Model/frameworkStage of scale-upFocus areaKey componentsProcess of developmentContextReference
Scalability considerationsPre-scale-upNon-specific/generalisableKey features of scalability of an intervention should consider:
1. Effectiveness
2. Reach and adoption
3. Human, technical and organisational resources
4. Costs
5. Intervention delivery
6. Contextual factors
7. Appropriate evaluation approaches
Literature review/expert Delphi processHigh-income countryMilat et al. 2012 [1]
Scalability considerationsPre-scale-upMaternal and newbornKey attributes of scalable health innovations:
1. Relevant and important – addresses a health need
2. Effective and advantageous – impacts positively on health and is advantageous over other innovations
3. Observable benefits – benefits and health impacts are visible
4. Acceptable to health workers and communities – culturally acceptable, works with existing community structures
5. Simple and low cost – low cost to implement at scale
6. Aligned and harmonised – builds on existing government health systems
7. Adaptable – adaptable to different contexts
8. Sustainable – low recurrent costs or local income-generating schemes
Qualitative study (interviews)Global health/low- and middle-income country (LMIC)Spicer et al. 2014 [22]
Scaling Up Management Framework (SUM) Scalability ChecklistPre-scale-upNon-specific/generalisableSeven key categories when considering scalability:
1. How convincing is the scaling strategy?
2. Is the intervention credible
3. How strong is the support for change?
4. Does the model have relative advantage over existing practices?
5. How easy is the model to transfer and adopt?
6. How good is the fit between the intervention and adopting organisation?
7. Is there a sustainable source of funding?
Literature and previous framework developmentGlobal health/LMICCooley et al. 2016 [18]
Taking innovations to scale – scalability checklistPre-scale-up/scalability checklistInternational Fund for Agricultural DevelopmentSeven key categories when considering scalability:
1. Is the model credible?
2. How observable are the model’s results?
3. How relevant is the model?
4. Does the model have relative advantage over existing practices?
5. How good is the fit between the intervention and adopting organisation?
6. How testable is the model?
7. Is there a sustainable source of funding?
Literature and case studiesGlobal health/LMICCooley & Linn 2014 [11]
Scaling up processScale-up processMaternal and newbornKey activities required to catalyse scale-up:
1. Designing innovations for scale
2. Integrating scale-up within programme plans
3. Building organisational capacity
4. Advocating effectively with government decision-makers
5. Generating and communicating strong evidence
6. Ensuring government involvement throughout the project
7. Invoking policy champions and network of allies
8. Aligning with government systems, policies, priorities and targets
9. Harmonising efforts with other development partners and implementers
10. Supporting and building the capacity of government for scale-up
11. Working with community leaders, media and others to stimulate diffusion of innovations among communities
Qualitative study (interviews)Global health/LMICSpicer et al. 2014 [22]
Framework for scaling up health interventionsScale-up processNon-specific/generalisableFramework for scaling up health interventions. Describes four key steps:
1. Set-up, to prepare the ground for introduction and testing of the intervention that will be taken to full scale
2. Develop the Scalable Unit, i.e. an early testing phase
3. Test of scale-up, to test the intervention in a variety of settings that are likely to represent different contexts that will be encountered at full scale
4. Go to full scale, to rapidly enable a larger number of sites or divisions to adopt and/or replicate the intervention
Literature review/Case studyGlobal health/LMICBarker et al. 2016 [23]
Scale-up of exclusive breastfeedingScale-up processHealth Promotion/Maternal and Child nutritionOutlined key steps for scaling up maternal breastfeeding programmes
1. Assess situation – create a policy environment
2. Define roles, relationships and responsibilities of all partners and establish agreements
3. Review technical support
4. Define programme strategy
5. Mobilise resources
6. Provide training and technical assistance
7. Develop and use monitoring and evaluation systems
8. Monitor coverage and quality
9. Measure impact and cost
10. Provide novel approaches for testing and continuing innovation
Literature reviewGlobal health/LMICBhandari et al. 2008 [19]
Schemata for considering context in scale-upScale-up processHIVPresents schemata for progression from efficacy to full scale implementation on three dimensions considering contextual elements using HIV as a case study. The three dimensions include:
1. Determinants and their pathways
2. Framing the research question
3. The design of the intervention contrasting between contextualised vs. standardised interventions
Literature review/Case studyGlobal health/LMICEdwards & Barker [24]
Scale-up frameworkScale-up processHIVFramework of 10 key domains critical to successful scale-up:
1. Fiscal support
2. Political support
3. Community involvement
4. Partnerships
5. Balancing flexibility/adaptability and standardisation
6. Supportive policy, regulator and legal environment
7. Building and sustaining strong organisational capacity
8. Transferring ownership
9. De-centralisation
10. Ongoing focus on sustainability
Literature review/case studyGlobal health/LMICHirschhorn et al. [25]
Program Assessment Guide – how to make decisions relating to design, implementation and scale-upScale-up processHealth promotion/nutritional programmesProgram Assessment Guide – designed as a structured, systematic method for countries to make decisions related to design, implementation and scale-up. Nine key steps across three categories.
Category 1: Laying the groundwork
• Step 1 – Clarifying the problem and proposed solution
• Step 2 – Setting vision and goals
• Step 3 – Reaching the most vulnerable
• Step 4 – Delivery system, mapping out the system
• Step 5 – Identifying people, roles and responsibilities
Category 2: Building or strengthening the programme
• Step 6 – meeting the needs
• Step 7 – action planning, including timeframes
Category 3: Strengthening the decision support and the enabling environment, which also includes:
• Step 8 – monitoring, evaluation and quality improvements
• Step 9 – organising, leading and managing the follow through
Case studiesGlobal health/LMICPelletier et al. [26]
Nine steps to scaling up – WHO ExpandNetScale-up processNon-specific/generalisableExpandNet framework involves nine steps:
1. Planning actions to increase the scalability of the innovation
2. Increasing the capacity of the user organisation to implement
3. Assessing the environment and planning actions to increase the potential for success
4. Increasing the capacity of the resource team to support scaling up
5. Making strategic choices to support vertical scaling up
6. Making strategic choices to support horizontal scaling up
7. Determining the role of diversification
8. Planning actions to address spontaneous scaling up
9. Finalising the scaling up strategy and identifying next steps
Literature and qualitative researchGlobal health/LMICWorld Health Organization ExpandNet [27]
Scaling up management framework (SUM)Scale-up processNon-specific/generalisableIncludes three key steps:
Step 1: developing a scaling up plan, including assessing for scalability
Step 2: establishing pre-conditions for scaling up
Step 3: implementing the scaling up process based on the identification of factors that can promote extension and sustainability
Same as Cooley & Linn [11], seven key categories when considering scalability:
1.Is the model credible?
2.How observable are the model’s results?
3.How relevant is the model?
4.Does the model have relative advantage over existing practices?
5.How good is the fit between the intervention and adopting organisation?
6.How testable is the model?
7.Is there a sustainable source of funding?
Literature and qualitative researchGlobal health/LMICCooley et al. 2016 [18]
Scaling up global health interventions: framework for successScaling up frameworkNon-specific/generalisableDescription of six components core to the scaling up process:
1. Attributes of specific tool or service being scaled up
2. Attributes of the implementers
3. Chosen delivery strategy
4. Attributes of the adopting community
5. Socio-political context
6. Research context
Literature review, interviewsGlobal health/LMICYamey [28]
Scaling up population health interventionsPre-scale-up and scaling up population health interventionsNon-specific/generalisableDescription of a four-step process for scaling up interventions:
1. Scalability assessment to assess the suitability of the intervention for scaling up
2. Develop a scaling up plan – create a vision of what scaling up will look like and a compelling case for action
3. Prepare for scaling up – securing resources and building a foundation of legitimacy and support for the scaling up plan
4. Scale-up – the main tasks that should be addressed during scale-up
Literature review and expert Delphi processHigh-income countryNSW Ministry of Health [13]
Readiness assessment – I-RREACH ToolImplementation planningCardiovascular diseaseThree stages of activity as part of the process to assess for implementation readiness, I-RREACH tool
• Stage 1 – Building a community profile
• Stage 2 – Gathering information on key stakeholder’s perspectives
• Stage 3 – Gathering information on community perspectives
There are eight key information domains:
1. Basic community descriptions
2. Leadership
3. Community programmes
4. Local understanding of the health issue
5. Resources and planning
6. Perceived fit of the intervention with community objectives
7. Infrastructure and technology
8. Readiness for community-based research
Community-based participatory research methodology and qualitative study (interviews)High-income country and LMICMaar et al. 2015 [29]
Implementation rules for scale-upImplementationMental healthDescribes five implementation rules for consideration when planning for the scale-up of mental health services:
1. Assess context
2. Identify priority care pathways and map them across skill needs
3. Specify decision supports, supervision and triage rules
4. Apply and use quality improvement practices
5. Plan for sustainability and capacity-building
Case studiesGlobal health/LMICBelkin et al. [30]
Five-step framework scaling up strategy of the European Partnership on Active and Healthy AgeingScaling up frameworkHealthy ageing/chronic respiratory diseasesOne of the priority areas of the strategy is to scale-up and replicate successful innovative integrated care models for chronic respiratory diseases. There is a five-step framework for developing scaling up strategies:
What to scale up
1. Step 1: database of good practices
2. Step 2: assessment of viability of the scaling up of good practices
3. Step 3: classification of good practices for local replication
How to scale up
4. Step 4: facilitating partnerships for scaling up
5. Step 5: implementation key success factors
There were also steps for individual services planning to scale up:
1. Planning and initiating the service
2. Setting up the system for change
3. Organisational process and design choices
4. Appropriate resourcing for equipment
5. Integration of clinical record systems
6. Creating capacity
Monitoring, evaluation and dissemination
Multi agency/multinational partnershipHigh-income countryBousquet et al. 2016 [31]