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.
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.
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.
Case study: Village Health Worker scheme in Gombe, northeast Nigeria
The Village Health Worker scheme was set up to deliver maternal, newborn and child health information to communities, linking communities to healthcare by training women from those communities known as ‘village health workers’. Our study revealed the six key steps that ensured the scheme was sustained by the Gombe state government:
1: The scheme was government-led and owned, with support from the civil society implementer and donor: a built-in phased ‘seamless transition’ meant responsibility for implementation and financing progressively shifted to government.
2: The scheme’s ‘adaptive management process’ involved planned reflection points and adapting the design when necessary.
3: Village Health Workers were motivated through strong supervision, by generous stipends, maternity leave and the acceptance and gratitude of communities.
4: Efforts to secure longer-term financial resources included advocating for sympathetic state politicians’ support and building a line-item for the scheme into the state health budget.
5: Considerable efforts were made to ensure the scheme was well institutionalised within the existing health system.
6: Efforts were made to foster community ownership and acceptance through key community structures known as Ward Development Committees.
All Fostering Innovation Sustainability related outputs can be found under Resources by selecting that theme from Research Areas.