Our respondents spoke about the importance of scaling donor-financed innovations to maximise longer term value from what were substantial donor investments, but accepted that innovations were commonly not scaled beyond their original project periods. Speaking about Nigeria, a development partner lamented: ‘If a project dies after funding, for me it is not a successful project…’; while in India a government official exclaimed: ‘The development sector is a graveyard of pilot projects!’ An enduring problem reported by our respondents was that short project periods of three to four years limited what could be achieved, which could be wasteful and created uncertainty for both implementers and governments. One government respondent in India captured this point: ‘…any donor funds should be at least six or seven years...because when you fund a four-year project…one year goes on recruitment and then the last six months is winding up…’. Nevertheless, as our three case studies show, scale-up of innovations that are part of short-term projects is possible. Based on our qualitative data we identified six critical actions adopted by implementers that were vital to the scale-up of one or more of our three case study innovations. These were:
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1.
Designing innovations for scale;
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2.
Generating evidence to influence and inform scale-up;
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3.
Harnessing the power of individuals;
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4.
Being prepared and responsive;
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5.
Ensuring continuity;
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6.
Embracing the principles of aid effectiveness.
The following sections explore each of these critical actions in turn.
Designing innovations for scale
The first critical action reported by our respondents was that scale-up had been integral to the design of our case study innovations: ‘...if you plan scale-up when your pilot’s over there are many things you can’t go back and correct…’ a government respondent from India explained. Some stakeholders pointed out that despite this happening, it was challenging to develop innovations that were scalable; indeed, their experimental nature carried the inherent risk that they would not be effective. Hence, despite putting substantial energy into the process of designing, testing and adapting innovations for scale, externally funded innovations commonly fail. A development partner reflected: ‘If you are lucky, that process will generate some… innovations that can be moved to scale...designing and testing and adapting only spits out a sample of innovations that are truly scalable if you are lucky...’. There were several common attributes of the case study innovations that respondents described as important to their scalability – these are listed as follows.
Perceived as effective
Our respondents reported that it was vital that the case innovations had been perceived as effective. In Ethiopia, randomised control trial evidence suggested that the sepsis case management innovation had impacted on health outcomes, that justified its scale-up: ‘It was taken because it produced results…,’ said an implementer. In Uttar Pradesh, government and civil society respondents noted that while evidence of quantitative impacts on health outcomes was not generated, our respondents reported that mSehat had demonstrably helped frontline workers to fulfil their roles more effectively. Impact data were also not available in Nigeria, however: ‘Because the project has such a widespread history…it was kind of like easy… to demonstrate effectiveness and impact,’ an implementer suggested.
Required modest resource inputs
Respondents explained that the innovations required financial resources that the government could afford and modest human resource inputs; this was essential for governments, with finite budgets and many competing priorities, to consider them for scale. Modest financial costs were important for ETS in Nigeria, where respondents were clear that paying drivers would not work: ‘...the programme is fairly sustainable…because drivers are giving up their time voluntarily’. mSehat was based on a low-specification, relatively low-cost handset and ASHA training was short; an implementer observed: ‘…it’s feasible to train them on this and it doesn’t take an entire lifetime to learn...’. Similarly, sepsis case management in Ethiopia was based on a short training period, which respondents explained was a very important aspect of its scalability. However, it had been difficult for implementers to balance committing substantial effort and resources to ensure the success of their innovations, with creating innovations that were not resource-intensive, and therefore scalable with limited government budgets. A government official in Uttar Pradesh summarised: ‘…at limited scale you can do anything – but we deliberately avoided doing such things that’ll not be possible to scale-up...’.
Acceptable to and incentivised frontline workers
Respondents pointed to the ways the innovations were considered acceptable to frontline workers and thereby incentivised their adoption. In Uttar Pradesh, mSehat’s user interface was designed to be easily understood by ASHAs, as one implementer explained: ‘…even those that have minimum qualifications will face no problem in adequately using the application once they get used to it through our training programmes’. ASHAs would also receive material incentives; entering data electronically meant faster performance-based payments than the former paper-based system, and the innovation reduced their workloads: their tasks such as counselling could be performed more quickly and meant they no longer carried heavy logbooks and other materials. Similarly, in Nigeria, the innovation incentivised taxi drivers involved in the scheme by allowing them to park their vehicles at the front of passenger loading queues, although it was accepted that this had been less effective in remoter areas with few taxis. In the three settings, goodwill and satisfaction incentivised frontline workers. Our respondents explained that in Ethiopia HEWs gained satisfaction by saving babies lives, which increased their acceptance and credibility within the community. Likewise, the innovation gave ASHAs in Uttar Pradesh more confidence to work among communities, and in northeast Nigeria branded tee shirts, caps and car stickers engendered feelings of pride and commitment. ‘We believe that God Almighty is going to reward all of us; that’s why many of us will not even collect money,’ said a driver. The ETS scheme had improved drivers’ standing among communities; a driver revealed: ‘…people see us as useless, good-for-nothing rascals…this programme’s an opportunity for us to change that image…’. The smart phone innovation in Uttar Pradesh was also described as aspirational, and as having novelty value: an implementer said: ‘…of course the novelty factor. Hey! We are doing something new and get a smartphone…’.
Acceptable to communities
The innovations met communities’ needs, were culturally acceptable and aligned with local cultural and traditional practices. Capturing this point, an implementer in Ethiopia remarked: ‘The community has to accept it and say, “this is actually something that can solve my problems”’, while in Nigeria a professional association representative said: ‘If the community does not accept you then there is no way you will be able to scale-up’. Ascertaining innovation acceptability depended on conducting formative research with community leaders, and the innovations were designed accordingly; for example, our respondents reported that the use of locally relevant visual and audio material for the mobile phone app in Uttar Pradesh was very important to its acceptance by communities.
Adaptable across diverse geographical contexts
The innovations were described by our respondents as being adaptable across diverse sociocultural contexts and to variations in the strength of the health system between different areas; an implementer summed up: ‘We keep saying it’s not one size fits all – in a country like Ethiopia we have to have different approaches and strategies in different areas’. Nevertheless, many features of the three innovations were also standardised, which made them cost effective at scale: ‘There might be some innovative variations…but in terms of...training, supervision, it’s all quite standardised’, clarified a development partner in Ethiopia. Similarly, in Nigeria, while there was flexibility to adapt to diverse geographical settings, ‘…the principles of the scheme have to remain the same...’, one implementer explained.
Generating evidence to influence and inform scale-up
A second critical action relates to evidence. In the three settings, our respondents reported that quantitative survey data establishing an innovation’s impacts on health outcomes, while important, had not been a critical part of decisions to scale innovations. Instead, first-hand, experiential evidence fostered emotional buy-in from government and other decision makers and influenced decisions to scale innovations. In addition, qualitative evidence documenting implementation processes, together with syntheses of secondary data, showed which innovations were feasible in practice and offered lessons about how they could be implemented at scale.
In Ethiopia, quantitative evidence of impacts on health outcomes generated by the implementer and periodically shared with the government had been necessary. However, this evidence had helped justify, rather than trigger, the decision, which was made before the end-line quantitative survey results were released. A development partner explained: ‘The policy breakthrough is never the data, the findings themselves...it’s the trust, the relevance, it’s being at the table, being able to show you support implementation...’. Indeed, first-hand evidence in the form of project visits was considered very influential: ‘We took [government decision makers] out, we showed them…that was very convincing to them...’, said an implementer in Ethiopia. Evidence of impacts did not influence the funder’s decision to scale ETS in Nigeria. Indeed, it had been difficult to collect such evidence because drivers were often unwilling to keep activity records, and some were illiterate. An implementer explained: ‘The driver’s responsibility is to get the woman to the health facility and often they go beyond the call of duty…when it comes to us pestering them for data sometimes they don’t see it as a priority’. Instead, the project’s plausibility compensated for the lack of data; a researcher said: ‘…who can resist saving mothers and babies’ lives? It’s a fantastically plausible project…’. Similarly, in Uttar Pradesh, evidence of health impacts did not influence the decision to finance mSehat. Instead, it was inspired by the fact that externally funded implementers had demonstrated that mobile phone-based innovations were implementable in India. An implementer reflected: ‘My experience in [Uttar Pradesh] has been more than the data, more than the impact [it’s about]…what’s happening in the field...they want to have a taste of it...’
Respondents in the three settings reported that implementers had collected qualitative evidence documenting implementation experiences and challenges, and that this evidence had been important in helping to scale the innovations effectively. In Ethiopia, such evidence showed the best ways to train HEWs to identify danger signs and administer antibiotics to sick babies, demonstrated that they could correctly refer more complex cases and that communities accepted this. While generating ‘local’ qualitative evidence was considered by our respondents to be vital, the implementer also synthesised evidence from other countries. This engendered acceptance by Ethiopia’s government and helped design the scaled innovation: ‘Save the Children’s role was…in bringing out other countries’ evidence and…making sure we have included the key interventions and followed already tested and feasible strategies,’ explained an implementer.
In Uttar Pradesh, mSehat adopted lessons from the multiple donor-funded pilot projects: ‘[mSehat tried to] absorb what was there in the field...all of these [pilot innovations] shaped it…,’ a development partner reflected. In Nigeria, lessons learned from implementing the innovation in Gombe State, including ways to increase driver retention, were important in informing the development of the innovation in Adamawa State. A development partner said: ‘…between all those different pieces of learning, even if they weren’t externally validated…some learning had been done’.
Harnessing the power of individuals
A third critical action to catalyse scale-up was implementers mobilising the support of policy champions perceived to have power, connections and influence at high levels from government and development partner agencies as well as traditional rulers, who could convince others that an innovation should be scaled. In the three settings, personal connections with government decision makers were described as being as, if not more, important than formally engaging government: ‘Having some experience of working in Nigeria it’s very important to engage on the personal level...,’ said an implementer. However, while building and maintaining relationships with powerful individuals had been vital, respondents acknowledged that with so much depending on this approach there was a risk that if that person left they would need to elicit support afresh.
In Uttar Pradesh, there was strong interest among key senior state government officials in using digital technology to address health needs in rural areas, including the Chief Minister, ‘…who very much believed that technology was the solution to many of the problems in administration…that was a major factor which paved the way for scale-up’, according to a government official. One particular government champion was reported as critical, as an implementer clarified: ‘…because he’s a renowned policymaker his words are looked up to with respect, so that helped us a lot. If you ask me any single thing…I think it’s [this person’s] vision and passion and belief - one [person] can make a difference!’ Similarly, in Ethiopia, a senior health official’s support was crucial to government agreeing to scale the innovation: ‘Convincing him, identifying him as a champion...that was very, very decisive’, an implementer explained. While in Nigeria the innovation was not scaled with government funding, seeking the acceptance and endorsement of senior government officials within Adamawa State was an essential part of introducing the innovation there; an implementer summarised: ‘The state [Commissioner for] Health was quite pivotal in allowing the programme to progress further’.
In Ethiopia, individuals from development agencies also contributed to the decision to scale the innovation; ‘What was the magic in Ethiopia? It does come down to some of the personalities!’ said a development partner, who also exclaimed that the commitment and belief of one individual had been vital: ‘[This person]…had a really good relationship with the Ministry of Health...and was a really proactive person. [Their] personality was definitely a factor...’. In Nigeria, traditional rulers were influential. Although some rulers were supportive of the introduction of innovations, many rulers embracing conservative views had resisted externally funded health programmes, as was the case in Adamawa State. Hence, the implementer had not engaged them there.
Being prepared and responsive
A fourth critical action was implementers both ensuring that scale-up was integral to their project plans and being responsive to change. The former involved conducting formative research to assess policy, health systems, geographical and sociocultural contexts to help to design innovations that were culturally appropriate and aligned with country health policies, programmes and targets. A development partner speaking about Nigeria summarised: ‘For scale-up to occur successfully we cannot rely on luck… if we go to the field without a prepared agenda, we’ve set ourselves up for failure’. Formative research also formed the basis of implementers’ advocacy plans, including identifying which actors they could work with and those they needed to petition for support. In Nigeria, formative research was important to ascertain which districts were sufficiently safe to implement the innovation in the context of the security situation.
While preparing for and anticipating scale-up had been important, policy contexts were not static in the three settings; changes in government administrations following elections in Nigeria and Uttar Pradesh inevitably led to changes in policy direction. As our respondents pointed out, implementers had to be responsive to change over the course of their project’s lifespan to remain relevant. A development partner in India explained: ‘Flexibility is key to go apace with government; anything that you work on, you have to keep their struggles, timelines, and accordingly adjust yours. You have to be patient for this’. In Ethiopia too, respondents stressed that health policy ideas changed quite often and hence it was important it was for donors and implementers to be responsive to the government’s thinking; an implementer said: ‘Knowing when to push your agenda and when to back off is really important’. Civil society implementers, in particular, needed to ensure they worked around the Ethiopian government’s agenda: ‘[It’s] the tricky role nongovernmental organisations have to balance in Ethiopia,’ one development partner revealed. Respondents suggested that a policy window emerged in Ethiopia created by three factors: increased political support following a study visit to Nepal, which demonstrated that community-based sepsis case management was feasible; the release of national figures showing limited improvements in neonatal and maternal mortality; and increased government confidence that its Health Extension Program was sufficiently robust to support additional innovations. An implementer explained: ‘[Events came together] in a certain pivotal moment where the Ministry decided there’s going to be a policy shift...’ The implementer responded to this 'pivotal moment', as a development partner reflected: ‘They were flexible and nimble...recognising hey, there’s an opportunity here!’
Ensuring continuity in the transition to scale
The fifth critical action to catalyse scale-up was the importance of continuity of implementers’ involvement in implementing the scaled innovations rather than, as is common among many projects, their involvement stopping when project funding ran out. Across our three case studies, the externally funded implementers contributed to delivering the scaled innovations. Transaid acted as lead implementer in the scale-up State of Adamawa; Save the Children was part of an implementing consortium for the Community-Based Newborn Care programme in Ethiopia; and in Uttar Pradesh, Intrahealth, the implementer of a foundation-funded project, became part of the public private partnership implementing mSehat. Our respondents suggested that it was particularly important to harness the experience of project staff within the scaled programme; an implementer in Uttar Pradesh captured: ‘Who else in that consortium has any on the ground experience of these things? So obviously [the implementer] brings a lot of that to the consortium…’ An implementer in Nigeria summarised the value of harnessing experience and project materials within the scaled programme: ‘If you want to scale [the innovation], what are the lessons learned in the pilot…? What mistakes have we made, what challenges have we faced…? That initial pilot helped to serve as a guide’.
In Ethiopia, study respondents reported that Save the Children had participated in workshops to develop and design the scaled innovation, including helping to draft implementation plans and guidelines, which also enabled them to influence government thinking. ‘...We used that as an opportunity to integrate as many newborn-care-related activities as possible in that implementation plan...,’ an implementer remarked. Helping to build the capacity of Ethiopian regional government staff and systems was also an important step to enabling the Government to implement the innovation at scale. An implementer said: ‘The [health] system may not be ready. So, when you go for scale-up you have to put into your programme other components to strengthen the health system...’
Embracing aid effectiveness principles
The sixth critical action pointed to by our respondents was that the externally funded implementers had embraced the aid effectiveness principles of country ownership, whereby the government took ownership of the innovation; alignment, meaning externally funded innovations fitted closely with country programmes, priorities and targets; and harmonisation, that is, coordination among donors and externally funded implementers.
Country ownership
In Ethiopia and Uttar Pradesh, it was critical that government owned the innovations rather than them being presented as donor projects. The Ethiopian government expected donors and their implementers to support country policies and therefore there was considerable involvement and consultation by the government in the development of the sepsis case management innovation; one implementer summed up: ‘Government is always in the driving seat’, while another implementer revealed:
If you see how things work in Ethiopia, [development partner] staff almost work for the government. They support the Ministry at all levels…they don’t just sit in their offices and work on their own projects. They are mindful that they are supporting the national health system….
Similarly, mSehat was presented as state government-led and owned rather than introduced by donors, although government respondents acknowledged that externally funded pilot innovations had encouraged the state government to finance mSehat, and that design features and learning from pilot projects had fed into the innovation’s design through extensive consultation between the state government and the implementers of the pilot projects. A development partner explained: ‘[The donor]…took a very small, critically important role – the triggering role. But now it’s government’s baby…’, while a government official clarified: ‘Funding is from [government]…The intellectual property will be 100% owned by [government]; that’s something we really care about’. Hence, in both settings, externally funded implementers closely engaged with government from inception and through the project’s life. In contrast, government ownership of ETS was limited, reflecting the fact that it was scaled in Adamawa state with donor, rather than government, funding. Indeed, our respondents explained that rural health programmes in northeast Nigeria were commonly donor financed, with state governments adopting a limited role in leading and coordinating externally funded programmes. Nevertheless, Transaid did closely engage with government actors to introduce the innovation: ‘…government officials were really happy about the programme because they said that they are ever ready to assist us if we need their help…,’ according to an implementer. Relationship building was therefore critical in the three settings; as suggested earlier, the support of individuals was vitally important. Thus, country ownership meant influential individuals in government having strong ownership of the innovations. In Ethiopia, an implementer remarked: ‘…ongoing informing and engagement was key for the government to really go ahead with the start of scale-up’.
Alignment
Respondents across three settings agreed that our case study innovations closely fitted with country priorities, programmes and targets. While Ethiopia received substantial development assistance for health, aligning with government programmes was critical for donors and their implementers. Respondents agreed that the sepsis case management innovation closely corresponded with country health programmes and was acknowledged as helping to achieve the government’s under-five mortality targets; hence government agreed to its scale-up. One implementer explained: ‘…it addresses a major health problem and that problem is a government priority, so it aligns with that. [And] it builds on the system; it isn’t a parallel system’. In Uttar Pradesh, reductions in donor budgets meant their roles were changing from funding agencies, with some influence on government, to providing technical assistance in support of government initiatives. An implementer said: ‘…it’s clearly not donors who are calling the shots here. They have to align with what the government wants.’ Hence, to influence the development of mSehat, pilot project implementers closely aligned their work with state government priorities. While in Nigeria the government did not finance the innovation at scale, the implementers did need to present the innovation as fitting with the Adamawa state government’s goals. As a development partner pointed out, the importance of presenting the work using the right terms helped align it with government thinking: ‘If we look at it as just ETS, then it doesn’t align with anything; if you call it [maternal and newborn child health] then it aligns with everything’.
Harmonisation
Harmonisation was also an important factor that contributed to scale-up. In Ethiopia, harmonisation was improving, largely due to the government taking a strong coordination role through the government-led National Child Survival Technical Working Group. An implementer observed: ‘The Technical Working Group was one voice, not a single organisation or individual voice… it was able to leverage, at least within that group, a consensus.’ Engaging with this group had been important to government’s adoption of sepsis case management; it gave Save the Children a legitimate channel to communicate with government and importantly, to demonstrate its willingness to harmonise its efforts with other actors. In Uttar Pradesh and Nigeria, however, harmonisation was problematic. A government official in India outlined the reality: ‘Everybody will talk of…not working in silos and all that. But… if there are two different donors and there are two projects in the same area they will not share any information…’ Limited harmonisation meant implementers could not benefit from what was learned by others, and poorly coordinated communication with government, and indeed competition for government attention, made decision-making relating to scale-up difficult. A development partner acknowledged that coordination at the federal level in Nigeria was improving, although not so at state and district levels:
When we sit over tea or coffee we say “yes”, and when we go back to our organisation we do our own things…we come with money and expertise and we confuse them with conflicting information…we disempower government and make them feel like puppets; we need to give them permission to be in charge because they are in charge, and we need to give them that power and support them.