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

Practical approaches for improving access to health care

The STEPS Centre and its affiliate partner Future Health Systems are working to challenge the prevailing concepts of “scaling up” in the health sector.

Download the Beyond Scaling Up flyer (pdf 800kb)

Publications

STEPS Working Paper 39: Beyond Scaling Up

Beyond Scaling Up: Pathways to Universal Access to Health Services (pdf 570kb)
By Gerald Bloom and Peroline Ainsworth

There is a growing impatience at national and international levels with the persistence of high burdens of ill health for which effective
interventions are available. Successful strategies need to combine large scale interventions and local adaptation and innovation. This paper explores alternative approaches for managing large scale health system changes in low and middle-income countries.

• Download this paper (pdf 570kb)
• Briefing: Beyond Scaling Up: improving access to health services (pdf 227kb)

Events

17 Nov 2010: Michael Loevinsohn: “New directions in environment-health research: implications for health systems”. Session at the First Global Symposium on Health Systems Research in Montreux, Switzerland.

18 Nov 2010: Gerald Bloom: “Beyond Scaling Up”. Session at the First Global Symposium on Health Systems Research.

Workshop on Beyond Scaling Up, 24-25 May 2010

A workshop was held at the Institute of Development Studies in May 2010. The objectives were to:

• explore approaches that have fostered innovation, rapid learning and large-scale impact in the health sector that incorporate context and social arrangements as central to learning and change
• identify practical approaches for collaboration between innovators, researchers, governments and funding agencies to strengthen the capacity of health systems to meet the needs of the poor.

Resources from the workshop

• Workshop agenda
• Presentation slides: view or download
• Photos of the workshop
• Video: interviews with participants

Topics covered at the workshop include:

• experiences with large scale health interventions
• local innovations
• new information communications technologies
• citizen/health system interactions and
• building an evidence base to take this work forward.

Workshop briefings

A set of briefings summarising the discussions at the meeting:

• Briefing 1 – Beyond Scaling Up workshop (pdf, 2.6MB)
• Briefing 2: Experiences with large scale health interventions (pdf, 1MB)
• Briefing 3: Exploring local innovation (pdf, 2.1MB)
• Briefing 4: Innovations in context of rapid change (pdf, 1.6MB)
• Briefing 5: How does the increased flow of information influence the speed and coherence of change? (pdf, 1.13MB)
• Briefing 6: Citizen/health system relations (pdf, 1.75MB)
• Briefing 7: Building evidence to support rapid change (pdf, 3MB)

About the Beyond Scaling Up project

How do we meet the health needs of the poor?

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.

Limits to blue-print 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.

An era of transition and uncertainty

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.