By Kate Hawkins, STEPS Centre member

The STEPS Centre and our affiliate Future Health Systems are launching a series of activities that challenge the thinking behind prevailing concepts of “scaling up” in the health sector.

There is an increasing awareness amongst policy-makers in developing countries that their government’s health services do not adequately meet the health-related needs of the poor.

Opinions on how to improve access to services vary. There is a long standing debate on the relative merits of blue-print approaches, which involve the replication of a well-designed intervention in multiple settings, and locally driven approaches, which rely exclusively on local innovation. Both have limitations.

The dominant response of developing country decision makers and donors has been to identify interventions which have been cost-effective in meeting health-related needs, often through pilot projects, and propose that these interventions are “scaled up” through the design of large programmes. Most discussions of scaling up focus explicitly or implicitly on the public sector and on the interventions which increased public resources should fund, whether through integrated or vertical approaches.

But a growing body of evidence indicates that the translation of increased resources into improved access is much more complex than the language of “scaling-up” implies. Health-related needs are diverse; they vary by setting and group. Blue-print approaches are rarely adaptive enough to work in predictable ways in different contexts, and are likely to produce unintended consequences, which can lead to poorly functioning and unsustainable interventions. In the case of locally driven approaches, it is more difficult to move to institutional scale and transmit learning from one site to another, so the impact may be local and modest.

Our work on “Beyond Scaling Up: Pathways to Universal Access” will explore emerging approaches that support local and scaled up innovations and facilitate rapid organisational learning about what works and what does not. It will contribute to discussions of practical approaches for ensuring that substantial increases in health financing lead to significant improvements in access to health services.

We are in the midst of a number of simultaneous transitions in demography, epidemiology, medical technology, information and communications technologies and economic and governance arrangements. We need to identify strategies for working with the uncertainties that these changes bring in addressing major health-related needs. We need to recognise that socio-technical systems and social institutions move along pathways that are profoundly influenced by their historical development. This both produces path dependency and opens opportunities for different models to emerge, and for alternative pathways to be built and promoted.