Course 8: Can an Idea Scale?

From Local to Global

Global health today is a collection of problems.  Similarly, rather than a coordinated movement, efforts to improve global health are diverse in their activities and impact.  Such efforts are often targeted at specific diseases and communities and are therefore limited in scope.  In order for a successful program to achieve sustainability and increase its impact, it must be able to scale from a local setting to a regional, national, or global one.(1)  While needed, this challenge is not easily met for several reasons.

Limited Resources

First, scaling up an initiative requires human and financial resources.  Global health programs should not encourage over-reliance on foreign support, and a program must achieve local sustainability before seeking to expand.  Oftentimes, global health initiatives succumb to the pitfall of scaling up programs before obtaining the resources to do so.  For example, many new NGOs fall into the pitfall of un-sustainability, as they operate for a summer or for a few years and then fade away.  The failure of NGOs to sustain their work stems from many inadequacies. Oftentimes, a lack of financial resources contributes to their demise.  In other cases, lack of volunteers, materials, and overall capacity prevents an NGO from achieving long-term sustainability. One researcher comments on the difference between “first generation NGOs” and “local self-reliance”:

“First generation strategies involve the NGO in the direct delivery of services to meet an immediate deficiency or shortage experienced by the beneficiary population, such as needs for food, health care or shelter. Such strategies are particularly relevant to emergency or humanitarian relief in times of disaster or crisis, such as famine, flood or war, when immediate human needs must be met.  Local self-reliance, on the other hand, concerns NGO involvement in long-term development work or capacity-building, with the intent that benefits would be sustained beyond the period of NGO assistance. Second generation strategies focus the energies of the NGO on developing the capacities of the people to better meet their own needs through self-reliant local action”.(2)

Local Realities Inhibit Global Scale

Local establishment and community involvement— two best practices in global health—can actually pose a difficulty to scaling up.  This can occur when a program or initiative becomes entrenched in the local environment.  In many ways, local dependence is crucial to the success of an initiative, as all too often there is a poor understanding about local culture and gender norms, insensitivity towards local needs, and imposition of Western structures and values.  While local tailoring is necessary, it may pose a challenge when an organization wishes to expand to a new region, country, or culture.  This is because the complexities and realities in one location may be entirely different in another.  The challenge becomes how to replicate a locally entrenched program to a different environment.

In order to prevent local realities from inhibiting global scale, all initiatives must be flexible.  This flexibility will allow each unique environment to shape the initiative toward success.  Thus, all initiatives should emphasize a grassroots approach, involving the community in key project decisions so that development work can be more responsive to their needs.  For instance, Unite For Sight’s overseas programs are led and managed by local eye care professionals, who are extremely knowledgeable about local disease etiologies, healthcare systems, and cultures. This ensures that local realities can shape the programs in each location and country.

Can an Idea Scale? (3)

In order for an innovative idea or program to achieve large impact, it must be scalable.  Five traits of scalable solutions include:

1. Real impact: Solutions without real impact should not scale.

2. Cost-effectiveness: Solutions that are too expensive will not scale.

3. Sustained behavior: Impact will not last without the right incentives and systems in place.

4. Replicability: Solutions have to be simple, systematic, and broadly adaptable to be replicated at scale.

5. A viable path to scale: A solution has to be designed to go to scale via one or some combination of these routes, each with their own strengths and flaws:

   • The market

   • Governments

   • Growing a very big organization

   • Co-opting other NGO’s

Case Study: Partners in Health(4)

The Partners in Health (PIH) model incorporates all five of these key traits for a scalable solution.  For example, flexibility and replicability are ensured by community partnerships and collaboration with the public sector creates a viable path to scale.  

Access to primary health care

A strong foundation of primary care is critical to successfully treating specific diseases, such as AIDS. When quality primary health care is accessible, the community develops new faith in the health system, which results in increased use of general medical services as well as services for more complex diseases. Therefore, PIH integrates infectious disease interventions within a wide range of basic health and social services.

Free health care and education for the poor

The imposition of user fees has resulted in empty clinics and schools in locations where PIH works, especially in settings where the burden of poverty and disease are greatest. Because both health and education are fundamental routes to development, it was found to be counterproductive to charge user fees for health care and education to those who need these services most and can afford them least. PIH works to ensure that cost does not prevent access to primary health care and education for the poor.

Community partnerships

Health programs should involve community members at all levels of assessment, design, implementation, and evaluation. Community health workers may be family members, friends, or even patients who provide health education, refer people who are ill to a clinic, or deliver medicines and social support to patients in their homes. Community health workers do not supplant the work of doctors or nurses; rather, they are a vital interface between the clinic and the community.

Addressing basic social and economic needs

Fighting disease in impoverished settings also means fighting the poverty at the root of poor health. Achieving good health outcomes requires attending to peoples’ social and economic needs. Through community partners, PIH works to improve access to food, shelter, clean water, sanitation, education, and economic opportunities.

Serving the poor through the public sector

A vital public sector is the best way to bring health care to the poor. While nongovernmental organizations have a valuable role to play in developing new approaches to treating disease, successful models can be implemented and expanded through the public sector to assure universal and sustained access. Rather than establish parallel systems, PIH works to strengthen and complement existing public health infrastructure.

Conclusion

To improve health care access and outcomes while narrowing equity gaps, the World Health Organization has promoted scaling up health care systems based on the principles of primary health care.(5) This broad movement toward scaling up successful programs and systems is an attempt to address the fragmented state of global health.  The expansion of equitable, integrated health systems and proven programs can meet the needs of communities and make quality health services available to everyone.  Since no single institution can accomplish such a task, it is important that non-profit, public, and private sectors work together to scale up interventions that have proven successful.

Footnotes

(1) Lane, C., & Glassman, A. (2007). Bigger and better? Scaling up and innovation in health aid. Health Affairs, 26(4), 935-948.

(2) Korten, D. C. (1987) Third generation NGO strategies: A key to people-centered development. World Development 15 (Suppl.), pp. 145–159.

(3) Adapted from: http://rainerfellows.org/home/howwedesign.

(4) Adapted from: www.pih.org.

(5) A Mills, F Rasheed and S Tollman, Strengthening health systems. In: DT Jamison, JG Breman and AR Measham et al., Editors, Disease control priorities in developing countries (2nd edn.), Oxford University Press, New York (2006).