Abstract
Background: The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. Methods: The study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention. Results: A shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up. Conclusions: Despite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.
| Original language | English |
|---|---|
| Article number | 35 |
| Pages (from-to) | 1-13 |
| Number of pages | 13 |
| Journal | BMC health services research |
| Volume | 23 |
| DOIs | |
| Publication status | Published - 16 Jan 2023 |
Bibliographical note
Funding Information:Ethical approval was provided by the Liverpool School of Tropical Medicine Research Ethics Committee, the Ghana Health Service Ethics Review Committee, the Uganda National Council for Science and Technology, the Ethics Committee of the School of Public Health (Makerere University) and the National Commission for Science and Technology in Malawi. The study followed ethical principles as set out by the Declaration of Helsinki. All participants provided informed consent.
Funding Information:
The study presented in this article was conducted as part of the PERFORM2Scale project. Perform2Scale is a five-year international research consortium aiming to develop and evaluate a sustainable approach to scaling up a district-level management strengthening intervention in different and changing contexts. The project is part of the European Union’s Horizon 2020 research and innovation programme, and this work was supported by grant number 733360. The authors would like to acknowledge all participants who gave their time to be interviewed, and the support the research teams provided in setting up the data collection.
Publisher Copyright:
© 2023, The Author(s).
Keywords
- Barriers and facilitators
- Comparative case-study
- District health management strengthening intervention
- LMICs
- Scale-up
