We studied how to scale-up and sustain maternal and newborn health innovations in Ethiopia, northeast Nigeria and Uttar Pradesh in India. We defined ‘scale-up’ as the adoption of donor-funded health innovations beyond original programme districts, and ‘sustainability’ as the longer-term implementation of donor-funded innovations that have been scaled-up.
How do you scale-up and sustain maternal and newborn health innovations?
Background
This is important because donors commonly fund health projects to test and develop innovative practices in low-resource settings, hoping that they will be adopted and scaled-up as part of existing health systems and programmes. But often these innovations are not adopted and scaled-up by country governments or sustained in the longer term. This wastes resources and time and can be counterproductive if it erodes trust in donor activities. It is important to understand how to sustain health innovations after donor funding ends.
Contribution of IDEAS
Our qualitative study involved interviewing stakeholders, including government decision makers, development agencies, civil society implementers of innovations, academics and experts. We carried out focus group discussions with frontline workers implementing innovations, such as community health workers, nurses and taxi drivers. In IDEAS’ first phase, in 2012 and 2013 we interviewed 150 stakeholders about the barriers and enablers to scaling-up of innovations in maternal and newborn health, the actions to catalyse scale-up and the effects of donor and implementer behaviour; and between 2014 and 2016 we interviewed 60 stakeholders to identify the most important actions required for scale-up. Between 2017 and 2019 we focussed on factors influencing longer-term sustainability by interviewing 145 stakeholders and conducting 51 focus group discussions with frontline implementers.
Results and implications
Based on our studies, our key messages on the factors influencing the scale-up and sustainability of innovations in maternal and newborn health:
1: Contexts. Whether donor funded maternal and newborn health innovations are scaled depends on where they are introduced. Contextual factors affecting scale-up in Ethiopia, northeast Nigeria and Uttar Pradesh included: how national health policy decisions were made; how maternal and newborn health issues were prioritised; government coordination of external partners; health systems capacity; and community demand for healthcare.
2: Actions. Despite the challenges, we identified certain actions that increased the chances of maternal and newborn health innovations being scaled-up. Six critical actions for innovation implementers are: 1) designing innovations to be scalable from the offset; 2) building a strong evidence base; 3) gaining the support of well-connected advocates and government personalities; 4) planning for scale-up while also being responsive to changes in political priorities; 5) supporting government throughout the transition to scale; 6) embracing aid effectiveness principles – alignment, harmonization and country ownership.
3: Behaviours. We found that scale-up and sustainability depend on donor and country government behaviours: country ownership of the innovation; alignment with national health policies, programmes and targets; harmonisation among multiple partners; transparency and accountability between donors and implementers and government; predictability of financial support, and civil society involvement in decision-making.
4: Ownership. Without strong country ownership of an innovation, it is unlikely to be scaled-up and sustained. Our studies highlighted the problem of donors introducing health interventions in a top-down way; donors should respond to country priorities and government requests for support, and work in partnership with governments. Successfully scaled and sustained innovations are usually country-led programmes supported by donors, rather than donor programmes introduced into countries (see case study).
5: Craft. Scaling-up is a craft and not a science, meaning that multiple human factors influence scale-up beyond developing a technically effective innovation and generating evidence of impacts: responding to politics; gaining the support of powerful ‘champions’ and emotional buy-in are all very important.