Module 7: Scaling Up Technology

Related to the stage of Mainstream Dissemination, the scale-up of technology is specifically identified as increased uptake among new user cohorts. It is not merely mass production and distribution from the supply-side; scale-up or spread is “an ecological phenomenon involving interactions among groups and their environments.”(1) Yet, beyond the approach to scale-up as an “ecological phenomenon,” the World Health Organization (WHO) has provided a definition from ExpandNet: “deliberate efforts to increase the impact of successfully tested health innovations so as to benefit more people and to foster policy and programme development on a lasting basis.”(2) This definition calls attention to the purposeful process of building institutional or environmental capacity that can sustain innovation, whether that is manifested in new technology, clinical practice, educational initiatives, or management protocol.

To achieve successful scale-up, it is important to identify the fundamental elements of the process. These include the innovation itself, the resource team creating opportunities for diffusion, the user organization(s) adopting and implementing the innovation, and the environment. Failures in scale-up tactics have generally been attributed to: inappropriate features of innovation design, preferences of potential users, environments of use (social, economic, or political), and methods of dissemination. In fact, an interview conducted by the Yale Global Health Leadership Institute revealed an example of attitudes common in the dissemination process:

“Pilot and pray is what most people do in global health. They pilot test some intervention in a district…and then hope for and look for a positive result and then are always somewhat surprised and disappointed when it doesn’t scale.” (Interview)

The AIDED Model of Scale-Up

To understand scale-up, the Yale Global Health Leadership Institute has created a five-part model, known as the AIDED Model. The five components, represented by each letter of “AIDED”, were identified according to trends in previously successful scale-ups, and can be applied to health products, behaviors, organizational forms, and businesses. Each component is described below:

ASSESS

Planning the dissemination of technology requires an understanding of the user groups’ receptivity to innovation. In the assessment of receptivity to use, it is helpful to distinguish between “need,” or what is vital to health improvement, and “demand,” or what is desirable given alternative options. Part of the level of interest will also involve the degree of support in political, regulatory, economic, socio-cultural, technological, and informational environments. If policies and infrastructure are built to promote uptake of new products and methodology, the environment positively influences user groups’ decisions and openness to innovation. Other factors include users’ past experiences with innovation, which may either help to avoid pitfalls in uptake or identify present barriers to success. Ultimately, assessment provides a necessary starting point for scale-up, identifying the level of receptiveness as well as key environmental forces that encourage or inhibit spread.

INNOVATE

Although technology design follows a comprehensive series of steps, the role of innovation in the context of scale-up is such that original designs may need reiterations or repackaging to fit with qualities of the user group and environment, as distinguished in the “ASSESS” component. By tailoring technologies to fit the “needs” or “demands” of particular users, it is easier for groups to see innovation as being acceptable or beneficial, and subsequently promote use among their social networks.

DEVELOP

Following reiterations or improvements in the “INNOVATE” phase, it will be important to address the environmental factors that will best support increased use of innovation. Factors may include policies, socio-cultural norms, and other infrastructural components that boost support and lessen resistance among stakeholders and opinion leaders. Since user group characteristics will vary according to the innovation, market, and current situation, development of structural support will also require tailoring to context, especially if the target change in behavior is substantial.

ENGAGE

Successful scale-up is impossible without actual incorporation of new technology into user group practice. Specifically, this step includes introducing, translating, and integrating innovation.

Introducing innovation involves bringing technology from outside to inside the user group, usually through “boundary spanners,” or individuals with both existing influence within the user group and connections to external resources. After a technology is presented, it needs to be translated in a way that facilitates use of the new information. Most directly, translation is the “development of practical guides, blueprints, and protocols in the spoken language of the user group.”(3) Yet sometimes the more effective method of translation is contextualization of new practices to connect with shared user group values. Translation of technology may be accomplished by the same “boundary spanners” involved in introducing the new product or technique, as well as the innovators or implementers themselves. Those who seek to frame innovation in a formal or informal language to best suit the user group are typically opinion leaders in the setting of scale-up. After innovation is primed for users, it will be integrated into routine practice, manifested either in immediate support (i.e. changes in legislation or cultural adaptation), or assimilation over time.

DEVOLVE

Devolution spreads innovation to more user groups through social networks. From social network mapping that identifies target user groups, to facilitating innovation sharing from current to new users, this component comprises the crux of scale-up: bringing innovation to (hopefully favorable) use among groups beyond the initial target. Often, the actual spread may be successful replication (more rare), adaptation to local context (more common), or failure (also common). Indicators for success in this process include the scope of knowledge and usage among large groups as measured by qualitative and quantitative data.

Interpretation

The five components of the AIDED Model review common elements in successful scale-up efforts. It is important to acknowledge that procedures may be nonlinear and progress through multiple feedback loops – not necessarily through the chronology of Assess, Innovate, Develop, Engage, and Devolve. Full scale-up has been deemed a “complex adaptive system,” due to the multiplicity of factors involved in planning and implementation, as well as the variable nature of outcomes. Even the most deliberate actions may lead to unpredictable consequences that aggregate quickly. For this reason, it is important to invest in infrastructure that facilitates data exchange, interventions that coordinate multiple tiers of action, and extra capacity to ensure flexibility of scale-up.

The AIDED Model is notable for creating a comprehensive pathway of technology dissemination. It begins on a micro-level by ensuring implementation in target user groups, and only expands uptake after observing successful results. The focus remains on groups – group behavior change and support, as well as the utilization of social networks and relationships. Nevertheless, there are limitations to its application. The AIDED model is still relatively new, and has not yet determined the long-term sustainability of innovation scale-up. Innovators and user groups alike serve to benefit from further testing in new contexts.

The WHO Model of Scale-Up

The WHO outlines a plan through nine steps that focus on each of the fundamental elements of scale-up: the innovation, resource team, user organization(s), and environment. Specific strategies include vertical scale-up (institutionalizing through systematic change), horizontal scale-up (growth or replication in different locations or groups), diversification (adding other functional innovations to the one under consideration), and spontaneous scale-up (expansion prompted by unexpected needs or circumstances).

Taken from the WHO publication, “Nine Steps for Developing a Scaling-Up Strategy,” the steps are as follows:(4)

Step 1: Plan actions to increase scalability

Issues significant to the scale-up process include credibility (if the innovation has sound evidence or proven advocates), relevancy (if the innovation adequately addresses problems-at-hand), advantage (if the innovation is advantageous over other alternatives), and appropriateness (if the innovation fits the needs and context of the user). In this planning stage, it is important to assess different aspects of these issues and determine how they may each affect the outcome of scale-up.

Step 2: Increase capacity of implementing user organization

The type of user organization will vary, from public to private or singular to combined institutions. Regardless of institution size or association, the user organizations most prepared for scale-up are composed of members with a perceived need for the innovation and the motivation to advocate for its introduction. Successful user organizations also prioritize capacity-building, either having already developed or having created plans to develop the organizational capacity for implementing technology. For instance, user demonstrations or pilot testing may be necessary for technical training, leadership, facilities and support, and monitoring and evaluation. During this process, user organizations may find that they are sufficiently prepared for implementation or that with appropriate changes, they can organize resources to achieve economies of scale.

Step 3: Assess environment and coordinate planning actions around success

Through ongoing assessment, it will be important to analyze environmental factors influencing scale-up. Understanding the political system, policy infrastructure, donor culture, relationship between government and civilians, and socioeconomic context of the site where expansion should occur is critical for providing a realistic understanding of outcomes. Some helpful questions that reflect aspects of the environment include:

• In what environmental sectors are individuals, groups, or organizations in support of or against innovation?

• How can supporters be recruited, and how can opponents be mitigated?

• What are the constraints to scale-up?

• Are there opportunities to build in flexibility to external change?

• Are there opportunities to create effective collaborations?

• What are current techniques of monitoring and evaluation in the environment?

Step 4: Increase capacity of resource team to support scale-up

Identifying an appropriate resource team involves recruiting individuals who had previously helped facilitate the development and testing of innovation. However, it is beneficial to add to that skill set other competencies such as managerial expertise and advocacy. An ideal resource team thereby includes two groups: a primary subset of facilitators and a group of technical specialists. Important qualities for the resource team consist of leadership, credibility, experience, stability, and sufficient size and/or access to human and capital resources.

In the process of increasing capacity of the resource team, it is important to acknowledge the distinction between resource team and user organization. The two groups maintain different roles and responsibilities. While close communication and interaction between the two will immensely help scale-up efforts, ownership still belongs to the user organization.

Step 5: Make strategic choices to support vertical scale-up

Scale-up on the vertical platform requires an understanding of macro-level policy, development, and financing. Given that many activities must institutionalize the innovation according to broad-based changes in the system, the first consideration is national program advocacy. If the government is interested and invested, vertical scale-up is often easier, albeit subject to complex measures. With non-governmental organizations or private sector involvement, there may be fewer formalities but other challenges to rapid institutionalization.

There are various recommendations for the strategic choices in scale-up. Regarding technology dissemination and advocacy, it is best to use multiple avenues, such as policy briefs, stakeholder meetings, individual activism, political influence, and traction in national policy or budget. Organizationally, resource teams should be skilled and adequately equipped with technical support, especially if they need to incorporate new technology to existing health care efforts. In consideration of costs and resource mobilization, teams should include financial needs and personnel in their budgetary proposals. Finally, a system of tracking activities is crucial to organized monitoring and evaluation.

Step 6: Make strategic choices to support horizontal scale-up

The connotation of horizontal scale-up indicates wide-scale reproduction of innovation. Yet rather than the all-too-common “mechanical repetition” of innovation, truly effective horizontal scale-up calls for expansion that will adapt to different environments. As such, recommended choices in dissemination, advocacy, and organizational process work toward this strategy.

When strategizing dissemination, it is best to engage key decision-makers that are critical to initiating outlets for expansion. In this process, advocacy may necessitate trials or testing phases for greater, evidence-based development. Communication about new technology must also be delivered in ways appropriate to potential supporters, using techniques that are focused and participatory in order to retain interest and investment. The WHO recommends a highly methodical organizational process. Specifically, teams should “evaluate [short-, mid-, and long-term] expectations about the scope and pace of scaling up and establish targets in light of the nature of the innovation, the strengths/capacities of the resource team, the user organization and the opportunities/constraints in the environment.”(5) Essentially, plans for scale-up should be adapted for use in the various sites, following the development of effective relationships with new partners and the involvement of stakeholders at an appropriate distance.

Choices regarding costs and resource mobilization also make use of mutually beneficial partnerships, allowing the potential to additionally connect financial needs to macro-level budgetary strategies. A system of tracking relevant indicators and statistics will also help with an organized monitoring and evaluation system.

Ultimately, sustainable innovation requires both horizontal and vertical scale-up (steps 5 and 6). To coordinate expansion along both planes, distribution should be gradual, building momentum in steps. Expansion that is too rapid can lead to lost or ineffective technology, drastically slowing scale-up if components are inherently difficult to implement.

Step 7: Determine the role of diversification

Diversification, or “functional scale-up,” may be applicable if relevant needs are identified that can supplement the original innovation. Often, the added intervention may promote scale-up efforts by drawing attention to a previously unidentified issue, creating demand for increased implementation. However, there is potential for both benefits and adverse effects, and it will be helpful to consider any negative consequences before full-scale diversification.

Step 8: Plan actions to address spontaneous scale-up

Unplanned dissemination of innovation may occur when either the user organization or resource team determines an unforeseen need or an event that creates a need. Although “spontaneous” scale-up is possible to wield using similar strategies as “planned” scale-up, implementation efforts done hastily “may lead to situations where the innovation is incompletely replicated and therefore does not yield the same results.”(6) Just as with the negative consequences of inappropriate diversification, adverse outcomes can threaten the credibility of the innovation itself, given errors in scale-up.

Step 9: Finalize scale-up strategy and identify the next steps

Effective strategy for scale-up requires more than a raw sum of the previous eight steps. It is necessary to balance different elements of the process, combining ingenuity with organization, prioritizing what is important, when it is needed, and what is feasible. When finalizing the scale-up strategy, an appropriate operational plan will identify effective action steps that address each recommended component of scale-up.

Footnotes

(1) Bradley, E., Curry, L., Pérez-Escamilla, R., et al. “Dissemination, Diffusion and Scale Up of Family Health Innovations in Low-Income Countries.” Yale Global Health Leadership Institute. October 2011.

(2) World Health Organization. (2010). “Nine steps for developing a scaling-up strategy.”https://apps.who.int/iris/bitstream/handle/10665/44432/9789241500319_eng.pdf;jsessionid=E2A22BB2E8F995424F742A7FC1A6E9BB?sequence=1.

(3) Bradley, E., Curry, L., Pérez-Escamilla, R., et al. “Dissemination, Diffusion and Scale Up of Family Health Innovations in Low-Income Countries.” Yale Global Health Leadership Institute. October 2011.

(4) World Health Organization. (2010). “Nine steps for developing a scaling-up strategy.”https://apps.who.int/iris/bitstream/handle/10665/44432/9789241500319_eng.pdf;jsessionid=E2A22BB2E8F995424F742A7FC1A6E9BB?sequence=1.

(5) Ibid.

(6) Ibid.