Last week we attended the first global symposium on health systems research with a group of emerging voices from the “Global South”. It was an extraordinary experience and you can catch some glimpses of this experience by reading what the Emerging Voices expressed on this blog, today and in the coming days. One of the things that struck me during this conference was the number of sessions that had scaling up in their title, I counted 79 with a related title for just 51 with the word access or 88 with the word financ*. Even two background papers to the conference got ‘scalingup’ in their titles. In global health, ‘scaling up’ is very often used in two contexts: toincrease access to ARV for AIDS patients and to implement high impact interventions for child survival for more beneficiaries.

Scaling up is an often heard term but what do people generally mean by this? I attended a session on quality improvement approaches for scaling up child survival and PMTCT strategies. One of the presenters reported on an excellent project in the Northern part of Ghana, where they improved quality of delivery in three districts by using intensive mentorship and regular coordination meetings. This just reminded me of what supervision should be in the “Kasongo approach”, nothing more. But then came the scaling up bit: They extended their projects from three to 300 hundred facilities, still in the North of Ghana. And there you could see that they already had to reduce their efforts to cope with the amount of work caused by the quality improvement activities.

When asked about their strategy to scale up their excellent project from the Northern regions to the rest of the country while maintaining quality, the presenter confessed that they hadn’t yet come up with a feasible strategy to achieve this and that to go from the local project to this regional level they had already given up on part of the good work done in the original settings.
Bringing effective interventions to scale is a challenge that all policy makers have to cope with when a well-meaning NGO comes to present the results of their project in one district and insists on taking it up as a national policy. No doubt that their project did work well but going from a few districts to national integration and coverage is a tall order in most countries. It is a gap that is also not easily filled by scaling up experts apparently.

When looking at an attempt to define the concept (onWikipedia), one sees that a “system is said to be scalable if it is suitably efficient and practical when applied to large situations”. This does not seem to apply to the above mentioned experiments, as they had to be reframed downwards in order to be scaled up. Hence there is a need to be more modest when using this term. “Scaling up” in my view should be kept for programmes that are implemented at a significant level of coverage, this is to say aiming at some form of universal coverage, especially in a symposium that set itself the objective of contributing to universal coverage.

blog post by David Hercot

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