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Table 3 Ten domains relevant to scaling up extracted from the literature review

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

Domain Definition(s) from primary sources
Fiscal support Ensuring adequate, flexible, reliable, and sustainable funding. This can be accomplished by incorporating a program into the national budget or the core budget of the funding agency.
Political support Mobilizing support for the program and protecting it from vested interests that may perceive it as a threat. Obtaining the support of political leadership and champions who ensure sustained, visible, and high-level commitment to the program at all levels of government and among relevant private-sector actors and civil society organizations.
Community involvement, integration, buy-in, and depth Striking an appropriate balance between participatory and expert or management-dominated approaches. Grounding scaling up in the principles of respect for and promotion of human rights and in the value of participatory and client-centered approaches. Adapting the program to local contexts and addressing the community’s identified needs. End users should be engaged early on and community champions involved in program design, implementation, and scale-up. Cultivating the depth of change necessary to support and sustain consequential change.
Partnerships Ensuring that domestic and external partners either continue or are engaged to support the program. Includes a systemic view of the variety of actors in the broader environment and a strategic understanding of how they can be leveraged to influence the scaling-up process. Determining and ensuring appropriate balance of scaling-up responsibilities—additive (full burden on one organization) or multiplicative (distributed across several organizations).
Balancing flexibility/adaptability and standardization Striking an appropriate balance between flexible, adaptive strategies and implementing a standard package of interventions. Ensuring that universally effective components of an intervention are applied while allowing for local adaptation. Evaluating, learning, and changing the approach as scaling up proceeds and developing a culture of adaptation, flexibility, and openness to change. Planning for context-specific delivery mechanisms effective in going to scale.
Supportive policy, regulatory, and legal environment Ensuring that a supportive policy, regulatory, and legal framework has been developed that allows for operating at scale. Inclusion of program in national policies.
Building and sustaining strong organizational capacity Addressing shortcomings in organizational capacity and enhancing the ability to deliver intended services and support. May include building local capacity and partnering with others able to operate the scaled program. Ensuring staff is sufficient, well distributed, and qualified with strong technical and program management abilities. Strengthening human capacities in management and implementation within national and sub-national governments.
Transferring ownership Shifting ownership so that it is no longer an “external” process controlled by reformers but instead becomes an “internal” process led by local actors with the capacity to sustain, spread, and deepen the results. May include successfully transferring intervention to adopting organizations.
Decentralization Determining and ensuring the appropriate balance of reach, influence, and resources provided by centralized authorities and local initiative, autonomy, spontaneity, mutual learning, and problem-solving provided by a decentralized approach. Decentralizing management and programmatic activities to the local level.
Ongoing focus on sustainability Creating a lasting programmatic and policy impact that produces enduring health benefits. Consistently focusing on sustainability and devising a strategy that includes plans and actions to ensure sustainability. This focus may inform the path chosen to achieve scale.