From scaling up to sustainability in HIV: potential lessons for moving forward

Case studies

Developing domains for delivery at scale

Our search yielded over 1,000 publications. Two authors (LRH, AI) reviewed the abstracts to identify potentially relevant articles, reports, and chapters for full review. We then reviewed bibliographies from identified publications for additional resources. In addition, we contacted experts in the fields of scaling up and international program capacity building for additional sources and reviewed the websites of major donors and international nongovernmental organizations (NGOs) involved in public health scale-up focusing on HIV and related fields. This process identified a total of 165 articles or other literature that described either scaling-up frameworks or programs that had achieved delivery at scale. From these we selected 15 sources that described frameworks and explicit characteristics or domains as important to scaling up successfully.

We then reviewed the 15 identified sources to: (1) identify differences and shared themes and concepts around scaling up; and (2) explore whether a synthesis of the frameworks was possible to develop a core set of domains. To reach these goals, each source was read by at least three team members to extract and code themes using modified grounded theory. An iterative group process was then used to merge the themes into domains. Domains were retained only if the themes they summarized were identified in three or more of the sources. Specific definitions for these domains were drawn from the primary sources. Any conflicting views or debates in the reviewed sources were represented in the definitions. The two authors who had extracted all 15 sources then reviewed the domains for consistency, and any differences in opinion were discussed with the remaining authors to develop final consensus.

Use of case studies for exploring sustaining delivery at scale domains

As noted, because none of the identified sources described frameworks or theoretical models focused primarily on sustaining delivery at scale (although some contained implicit or explicit discussions related to aspects of sustainability), we used the case studies to begin to explore the applicability of the scale-up domains for programs focused on sustaining delivery at scale. The mapping of the domains to the cases was also desigend to identify additional domains that might be relevant to sustainability.

Defining “scale” and “scaling up”

We found that the definition of the term “scale” in the literature has expanded and evolved in the last 30 years, without an accepted and widely utilized version identified [10]. Earlier definitions of scale are narrow, reflecting quantitative measures of program scope, such as number of sites covered or beneficiaries served [14, 15]. In more recent literature, most scholars view these definitions as insufficient. The CORE group, a collaboration of health professionals from international development NGOs, has proposed a broader conception of “scale”, defined as “widespread achievement of impact at affordable cost”, with “impact” serving as a function of coverage, effectiveness, efficiency, local ownership promoting sustainability, and equity [15]. CORE’s definition closely reflects those Coburn proposed [14] in the educational arena. Coburn’s framework included sustainability, spread, and shift in ownership, along with a fourth dimension: deep and consequential change.

Similar diversity is found in the scope of what “scaling up” entails. In a literature review on scaling up, Mangham and Hanson [10] argue, “scaling up is primarily used to describe the ambition or process of expanding the coverage of health interventions, though the term has also referred to increasing the financial, human, and capital resources required to expand coverage.” Although “scaling up” is still primarily employed to describe geographical reach, Uvin and Miller’s 1996 article, “Paths to Scaling Up”, sparked a more sophisticated dialogue by including dimensions beyond quantitative indicators: in addition to quantitative (geographic spread or expansion in size) scale up, they define “functional” scale-up as expanding the scope of activity; “political” scale-up as influencing the political process; and “organizational” scale-up as enhancing organizational capabilities and sustainability [16].

The World Health Organization’s global network of public health professionals, ExpandNet, proposed that scaling up involves “efforts to increase the impact of health service 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” [11]. This definition highlights the scientific or technical dimension (proven interventions), the political dimension, and the challenge of sustainability.

Scaling-up domains

The 15 sources we reviewed differed in their approach to studying and explaining scale and the overall intent of the work (descriptive versus normative). Some included frameworks designed to assist program managers, implementers, and other actors in making practical decisions about scaling up. Some sources also provided insight into key capabilities or choices associated with success or failure in achieving scale. Despite the disparate nature of the sources studied, we were able to synthesize domains that consolidated much of the conceptual thinking about scale and scaling up found in the literature.

The reviewed literature also identifies several other decision points in planning the scaling up of public health programs that are likely to inpact sustaining delivery at scale and reflect the complexity of replication of a program. These choices include decisions about when and if to transition to another organization (including the government) and the importance of fidelity to an effective model versus the latitude to adapt to local conditions [23].

Sustaining delivery at scale domains: lessons learned from HIV/AIDS

While we found a general domain of an “ongoing focus on sustainability”, there were few references to how the other domains were relevant to sustaining delivery at scale. Our review of the 11 case studies showed each of the 10 domains had elements relevant to how these programs worked to sustain delivery at scale. Some of the domains became even more critical as programs transitioned from having achieved scale to aiming for sustaining delivery at scale. For example, for Domain 5 (balancing flexibility/adaptability and standardization), we found that as programs achieve scale, many struggle to balance continued local innovation with standardization under central control. The case studies suggest that program monitoring and evaluation and elements of financial control and oversight, as well as areas where there are economies of scale such as supply chain management and training, can be successfully standardized and contribute to sustainability. Elements of delivery models that will continue to need iterative adaptation include generating local demand and mobilizing communities.

The Avahan Indian AIDS Initiative, a large-scale HIV prevention program of the Bill and Melinda Gates Foundation, for example, used similar metrics and financial management structures across its seven “state lead partners” and 137 district-level NGOs that were implementing HIV prevention programs. But each NGO used a unique set of activities to achieve its goals and reach the local target population. Avahan achieved high levels of success using this model balancing management and monitoring with local adaptation of interventions to reflect targeted populations. To date, Avahan’s model is being evaluated as it transfers its model to the public sector. Further research is required to understand how and where flexibility ensures ongoing impact and where it poses a threat.

While Domain 7 (building and sustaining strong organizational capacity) was critical to sustaining delivery at scale, an even broader long-term approach to capacity was also found to be important. This approach should expand to include a focus on providers and key staff implementing the program by investing in long-term human resource retention and development. For example, a mature program might lose experienced staff if there is little room for professional development or “burnout” from prolonged time working in weak health systems and if there are ample opportunities to attain better-paying positions elsewhere. If programs do not plan for retention and staff turnover, there will be inadequate numbers of appropriately trained new staff (both internally for program management and for implementers as programs transfer to public sector), threatening sustainability of gains.

Therefore, a focus not only on meeting human resource demands as programs scale, but on developing internal human resources management to improve retention and maintenance of program expertise is likely to be essential for sustaining delivery at scale. Organizations featured in the case studies that have successfully sustained delivery at scale have deliberately created a culture of commitment and optimism among their employees to address staff retention [24, 25]. The director of The AIDS Support Organization (TASO), a Ugandan NGO, for example, looked for motivated young people to hire and gave them significant responsibility. The antiretroviral therapy coordinator explained, “[Working at TASO] was very, very exciting, and people were so empowered with hope—'I can do this! This is work that was once restricted to doctors, but now I’m actually saving lives!’” The director valued good management skills over HIV knowledge in hiring and made sure staff members felt that they had a career advancement path within the organization.

The World Health Organization/ExpandNet framework includes equity as an important component in scaling up [11], but it was not prominent in other sources reviewed. As the vision for scaled programs is increasingly focused on transition to the public sector as the main pathway to sustainability, an emphasis on equity (i.e., a focus on ensuring access that includes the most vulnerable) needs to be an increasingly important driver of decisions and delivery models to ensure that this sector is able to fulfill the role of serving the entire population [26]. Iran’s Triangular Clinic, for example, served HIV-positive individuals from various risk groups, many of whom were injection drug users who had been ostracized from their families and society at large. Assisting all populations affected by HIV, not just those easiest to reach or least stigmatized, initially led to a profound local impact and was later adopted by the national program, scaled up around the country, and integrated with the health care system. We would therefore propose an 11th domain: emphasizing equity.