Scaling up: a summary and “call to action”

1. Scaling up: a summary and “call to action” Lawrence Haddad IDS December 2008

2. Key learnings 1 • Richness of experience in scaling up • “Small is beautiful but large is necessary” (F. Abed) • 65 presentations (Mushtaq Chowdhury) • Effective, efficient, expand (F. Abed) • MSI’s typology – 8 types x 5 success x 3 roles x 6 how x 6 who x 3 what = 12,960 variants (Richard Kohl) • “Scaling is not just about multiplication” (Mushtaq Chowdhury) • Clarified some key concepts • Originators, intermediaries and adopters • Getting to scale vs. operating at scale • Capability vs. Capacity

3. Key learnings 2 • Scaling up needs to be planned for at the originator stage • spontaneous diffusion is unusual (yoga?) • pathways to scale at efficacy stage JSI-Hopkins ((stephen Hodgkins) • need to anticipate barriers to change (Sylvia Vriesendorp) • think through the incentives (Quayyumi Zahidul, Charles Slaughter) • need supportive context “regulation is the oxygen of scaling up” (Stefan Nachuk), varying ICDS by governance levels by state (Rajani Ved) • Scaling up requires a different skill set to that for developing the technology/process/idea • political (Richard Kohl, Alec Cumming, Tahmeed Ahmed) • organisational (Charles Larson) • communication/ICT (Tina Sangvhi, Prita Chathoth) • risk assessment (Hilary Standing) • management (Peter Fajans, Anna Heard) • mobilisation (Neela Mukherjee) • some sector specificity but more to gain from cross-sector learning than most issues (Greg Chan, microfinance)

4. Key learnings 3 • needs trial & error • “solved one problem at a time” BRAC and immunization in in Afghanistan (Jalaluddin Ahmed) • analysis & adaptation ORT (Richard Cash and F. Abed, SM Ahmed) • “plan B” in SUZY (Tracy Koelhmoos) • relentless optimism • “10 days of zinc tablets is a huge barrier” (Charles Larson) • brutal honesty • “no eye wash please” (Tahmeed Ahmed) • impact & costs • (Richard Kohl, Tina Sanghvi), • Importance of M&E, research • “if it has not been written down it has not been done” (Uma Nath) • “monitoring for results while scaling up” (Abbas Bhuiya, SM Ahmed) • “disjuncts between knowledge and practice” (Imran Matin) • but M&E of the ability to scale up missing? (Richard Kohl) • internal accountability & closing the feedback loops • “if things go wrong, what happens?” (Richard Kohl, Anna Heard, Sylvia Vriesendorp)

5. Key learnings 4 • is scaling up getting harder? • moving into areas with fewer scalars (e.g. lack of consensus in definitions & indicators, fewer activists in complementary feeding vs BF, Tina Sanghvi) • more cluttered infrastructure (new vaccines, Carole Presern, GAVI) • complexity framework (Tracy Koehlmoos) • may require a different kind of research and analysis • “evidences and evidence” (Tim Evans) • funding • “not cheap to do scale up” (Charles Larson) • “funding is not that fundamental a constraint to scale up” (Stefan Nachuk) • “overfunding” (Richard Cash) • “use platforms when they exist” (Tina Sanghvi)

6. Things I did not hear so much about… • What went wrong? • Scaling down, scaling out ? • Uneven scaling - exclusion and inclusion in going to scale • Role of donors • financiers or venture capitalists? • barriers or enablers ? – the desire for speed • donors’ incentives to scale their own work • What the health field needs to change to be more effective in scaling up – skills, organisation, partners?

7. “Call to Action” More effective scaling up requires health community to develop new capabilities • Consensus and clarity on concepts is needed • Health hierarchies need to be softened--is there a big enough “repaired umbrella” (Una Lynch) in health for political, institution, managerial, cultural skill sets to get out of the rain? • Location of skills development and training—what is the minimum needed in the above areas for health educators and health professionals? Boundary crossers or in-house specialists? • Not the usual partners – who are your key scaling up partners? “People like us”? Unlikely. • Different types of analysis – “evidences and evidence” (the hammer and the nails) • Donors—what should they do differently? • What should BRAC and NGOs do differently?