A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa
Open accessAbstract
BACKGROUND: Scaling up complex health interventions to large populations is not a straightforward task. Without intentional, guided efforts to scale up, it can take many years for a new evidence-based intervention to be broadly implemented. For the past decade, researchers and implementers have developed models of scale-up that move beyond earlier paradigms that assumed ideas and practices would successfully spread through a combination of publication, policy, training, and example. Drawing from the previously reported frameworks for scaling up health interventions and our experience in the USA and abroad, we describe a framework for taking health interventions to full scale, and we use two large-scale improvement initiatives in Africa to illustrate the framework in action. We first identified other scale-up approaches for comparison and analysis of common constructs by searching for systematic reviews of scale-up in health care, reviewing those bibliographies, speaking with experts, and reviewing common research databases (PubMed, Google Scholar) for papers in English from peer-reviewed and "gray" sources that discussed models, frameworks, or theories for scale-up from 2000 to 2014. We then analyzed the results of this external review in the context of the models and frameworks developed over the past 20 years by Associates in Process Improvement (API) and the Institute for Healthcare improvement (IHI). Finally, we reflected on two national-scale improvement initiatives that IHI had undertaken in Ghana and South Africa that were testing grounds for early iterations of the framework presented in this paper. RESULTS: The framework describes three core components: a sequence of activities that are required to get a program of work to full scale, the mechanisms that are required to facilitate the adoption of interventions, and the underlying factors and support systems required for successful scale-up. The four steps in the sequence include (1) Set-up, which prepares the ground for introduction and testing of the intervention that will be taken to full scale; (2) Develop the Scalable Unit, which is an early testing phase; (3) Test of Scale-up, which then tests the intervention in a variety of settings that are likely to represent different contexts that will be encountered at full scale; and (4) Go to Full Scale, which unfolds rapidly to enable a larger number of sites or divisions to adopt and/or replicate the intervention. CONCLUSIONS: Our framework echoes, amplifies, and systematizes the three dominant themes that occur to varying extents in a number of existing scale-up frameworks. We call out the crucial importance of defining a scalable unit of organization. If a scalable unit can be defined, and successful results achieved by implementing an intervention in this unit without major addition of resources, it is more likely that the intervention can be fully and rapidly scaled. When tying this framework to quality improvement (QI) methods, we describe a range of methodological options that can be applied to each of the four steps in the framework's sequence.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Examples of scale-up strategies include train-the-trainer initiatives, infrastructure development (supply chains, data systems), quality improvement collaboratives, benchmarking, policy advocacy, and recognition systems.
“Examples of scale-up strategies include train-the-trainer initiatives, infrastructure development (supply chains, data systems), quality improvement collaboratives, benchmarking, policy advocacy, and recognition systems [42, 43].”
From Beyond “implementation strategies”: classifying the full range of strategies used in implementation science and practice (2017) · cites this paper as [43]
Scale-up strategies target motivation and capacity to integrate a specific EBI into practice.
“Motivation and capacity to integrate a specific EBI into practice”
From Beyond “implementation strategies”: classifying the full range of strategies used in implementation science and practice (2017) · cites this paper as [43]
Outcomes used to assess effectiveness of scale-up strategies are motivation and capacity to implement, and actual implementation of an EBI across multiple settings.
“Motivation and capacity to implement, and actual implementation of an EBI across multiple settings”
From Beyond “implementation strategies”: classifying the full range of strategies used in implementation science and practice (2017) · cites this paper as [43]
Scale-up strategies target level of individual, inner setting, and outer setting.
“Targets level of individual, inner setting, and outer setting”
From Beyond “implementation strategies”: classifying the full range of strategies used in implementation science and practice (2017) · cites this paper as [43]
Another two articles employed frameworks to support spread and scale-up efforts, although they did not draw on relevant approaches such as the Going to Full Scale framework, 3S infrastructure, or the Dynamic Sustainability framework.
“Another two articles employed frameworks to support spread and scale-up efforts, although they did not draw on relevant approaches such as the Going to Full Scale framework, 3S infrastructure, or the Dynamic Sustainability framework [58-60].”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [59]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Rogers, E. M., Singhal, A., & Quinlan, M. M. (2019) · Routledge eBooks · doi:10.4324/9780203710753-35 · Cited by 37,557 · see citing works
Valente, T. W. (2003) · Genetics in Medicine · doi:10.1097/01.gim.0000061743.67794.c4 · Cited by 20,555 · see citing works
Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009) · Implementation Science · doi:10.1186/1748-5908-4-50 · Cited by 14,496 · see citing works
Crossing the Quality Chasm: A New Health System for the 21st Century
Baker, A. (2001) · BMJ · doi:10.1136/bmj.323.7322.1192 · Cited by 10,754 · see citing works
Social Foundations of Thought and Action
Bandura, A. (2002) · SAGE Publications Ltd eBooks · doi:10.4135/9781446221129.n6 · Cited by 9,948 · see citing works
Crossing the Quality Chasm: A New Health System for the 21st Century
Bloom, B. S. (2002) · JAMA · doi:10.1001/jama.287.5.646-a · Cited by 3,732 · see citing works
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance
(1997) · Quality Management Journal · doi:10.1080/10686967.1998.11919154 · Cited by 2,876 · see citing works
The Millennium Development Goals Report 2014
United Nations, U. N. (2016) · Human Rights Documents online · doi:10.1163/2210-7975_hrd-9927-2014005 · Cited by 2,270 · see citing works
Technology Diffusion and Organizational Learning: The Case of Business Computing
Attewell, P. (1992) · Organization Science · doi:10.1287/orsc.3.1.1 · Cited by 1,401 · see citing works
Ferlie, E. B., & Shortell, S. M. (2001) · The Milbank Quarterly · doi:10.1111/1468-0009.00206 · Cited by 1,335 · see citing works
The improvement guide : a practical approach to enhancing organizational performance
Langley, G. J. (1996) · Jossey-Bass Publishers eBooks · Cited by 884 · see citing works
Evidence for the impact of quality improvement collaboratives: systematic review
Schouten, L. M. T., Hulscher, M., van Everdingen, J. J. E., Huijsman, R., & Grol, R. P. T. M. (2008) · BMJ · doi:10.1136/bmj.39570.749884.be · Cited by 683 · see citing works
Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994) · Cited by 644 · see citing works
Social marketing: strategies for changing public behavior
(1990) · Choice Reviews Online · doi:10.5860/choice.27-3939 · Cited by 644 · see citing works
Understanding pathways for scaling up health services through the lens of complex adaptive systems
Paina, L., & Peters, D. H. (2012) · Health Policy and Planning · doi:10.1093/heapol/czr054 · Cited by 534 · see citing works
Microsystems in Health Care: Part 1. Learning from High-Performing Front-Line Clinical Units
Nelson, E. C., Batalden, P. B., Huber, T. P., Mohr, J. J., Godfrey, M. M., Headrick, L. A., & Wasson, J. H. (2002) · The Joint Commission Journal on Quality Improvement · doi:10.1016/s1070-3241(02)28051-7 · Cited by 451 · see citing works
Scaling up in international health: what are the key issues?
Mangham, L. J., & Hanson, K. (2010) · Health Policy and Planning · doi:10.1093/heapol/czp066 · Cited by 303 · see citing works
Scaling up global health interventions: A proposed framework for success
Yamey, G. (2011) · PLoS Medicine · doi:10.1371/journal.pmed.1001049 · Cited by 295 · see citing works
Hanson, K., Ranson, M. K., Oliveira‐Cruz, V., & MILLS, A. J. (2003) · Journal of International Development · doi:10.1002/jid.963 · Cited by 249 · see citing works
Arifeen, S. E., Hoque, D. M. E., Akter, T., Rahman, M., Hoque, M. E., Begum, K., Chowdhury, E., Khan, R., Blum, L. S., Ahmed, S., et al. (2009) · The Lancet · doi:10.1016/s0140-6736(09)60828-x · Cited by 236 · see citing works
A Framework for the Dissemination and Utilization of Research for Health‐Care Policy and Practice
Dobbins, M., Ciliska, D. K., Cockerill, R. W., Barnsley, J. M., & DiCenso, A. (2002) · Worldviews on Evidence-based Nursing presents the archives of Online Journal of Knowledge Synthesis for Nursing · doi:10.1111/j.1524-475x.2002.00149.x · Cited by 230 · see citing works
Victora, C. G., Black, R. E., Boerma, J. T., & Bryce, J. (2010) · The Lancet · doi:10.1016/s0140-6736(10)60810-0 · Cited by 207 · see citing works
Lanham, H. J., Leykum, L. K., Taylor, B. S., McCannon, C. J., Lindberg, C. C., & Lester, R. T. (2012) · Social Science & Medicine · doi:10.1016/j.socscimed.2012.05.040 · Cited by 206 · see citing works
Eliminating mother-to-child HIV transmission in South Africa
Barron, P., Pillay, Y. G., Doherty, T., et al. (2012) · Bulletin of the World Health Organization · doi:10.2471/blt.12.106807 · Cited by 166 · see citing works
Bryce, J., Victora, C. G., Habicht, J., Vaughan, J. P., & Black, R. E. (2004) · American Journal of Public Health · doi:10.2105/ajph.94.3.406 · Cited by 163 · see citing works
Translating research into practice: speeding the adoption of innovative health care programs.
Bradley, E. H., Webster, T. R., Baker, D. I., Schlesinger, M. J., Inouye, S. K., Barth, M. C., Lapane, K. L., Lipson, D., Stone, R., & Koren, M. J. (2004) · PubMed · Cited by 156 · see citing works
The Importance of Context in Implementation Research
Edwards, N. C., & Barker, P. (2014) · JAIDS Journal of Acquired Immune Deficiency Syndromes · doi:10.1097/qai.0000000000000322 · Cited by 135 · see citing works
Self-citationThe next phase of healthcare improvement: what can we learn from social movements?
Bate, P. (2004) · BMJ Quality & Safety · doi:10.1136/qshc.2003.006965 · Cited by 108 · see citing works
The Accelerated Child Survival and Development programme in west Africa: a retrospective evaluation
Bryce, J., Gilroy, K., Jones, G., et al. (2010) · The Lancet · doi:10.1016/s0140-6736(09)62060-2 · Cited by 85 · see citing works
Saving 100 000 lives in US hospitals
McCannon, C. J., Schall, M. W., Calkins, D. R., & Nazem, A. G. (2006) · BMJ · doi:10.1136/bmj.332.7553.1328 · Cited by 82 · see citing works
Self-citationUsing a Framework for Spread: The Case of Patient Access in the Veterans Health Administration
Nolan, K. M., Schall, M. W., Erb, F., & Nolan, T. W. (2005) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(05)31045-2 · Cited by 63 · see citing works
Self-citationLearning Networks for Sustainable, Large-Scale Improvement
McCannon, C. J., & Perla, R. J. (2009) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(09)35041-2 · Cited by 47 · see citing works
Twum-Danso, N. A. Y., Akanlu, G. B., Osafo, E. L. K., Sodzi-Tettey, S., Boadu, R. O., Atinbire, S., Adondiwo, A., Amenga-Etego, I., Ashagbley, F., Boadu, E. A., et al. (2012) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzs060 · Cited by 43 · see citing works
Self-citationMoving From Research to Large-Scale Change in Child Health Care
Bergman, D. A., & Beck, A. L. (2011) · Academic Pediatrics · doi:10.1016/j.acap.2011.06.004 · Cited by 20 · see citing works
Options for large-scale spread of simple high-impact interventions. Technical report.
Mr, M., Kl, D., & Cj, M. (2010) · Cited by 14 · see citing works
Guide for monitoring scale-up of health practices and interventions. Manual.
Adamou, B., Curran, J. S., Wilson, L. A., Na, D., Jennings, Lundgren, R., Kiesel, R., & Hardee, K. (2013) · Cited by 3 · see citing works
Flagged first, then by citations
Research works printed but not linked: 7
- [15]Implementing Best Practices Consortium A guide for fostering change to scale up effective health services 2007 Cambridge Management Sciences for Health
- [26]Institute for Healthcare Improvement The breakthrough series: IHI’s collaborative model for achieving breakthrough improvement (IHI innovation series white paper) 2003 Cambridge Institute for Healthcare Improvement
- [34]Moen R A guide to idealized design 2002 Cambridge Institute for Healthcare Improvement
- [36]Reinertsen JL Bisognano M Pugh MD Seven leadership leverage points for organization-level improvement in health care (second edition) (IHI innovation series white paper) 2008 Cambridge Institute for Healthcare Improvement
- [37]Swenson S Pugh M McMullan C Kabcenell A Book high impact leadership: improve care, improve the health of populations, and reduce costs (IHI white paper) 2013 Cambridge Institute for Healthcare Improvement
- [38]McCannon CJ Schall MW Perla RJ Planning for scale: a guide for designing large-scale improvement initiatives (IHI innovation series white paper) 2008 Cambridge Institute for Healthcare Improvement
- [41]Mate K Sifrim Z Provost L Sustainability of improvement interventions (IHI 90-day R&D project final summary report) 2011 Cambridge Institute for Healthcare Improvement
Cited by
Sorted by citations
Leeman, J., Birken, S. A., Powell, B. J., Rohweder, C., & Shea, C. M. (2017) · Implementation Science · doi:10.1186/s13012-017-0657-x · Cited by 544 · see citing works
Means, A. R., Kemp, C. G., Gwayi-Chore, M.-C., Gimbel, S., Soi, C., Sherr, K., Wagenaar, B. H., Wasserheit, J. N., & Weiner, B. J. (2020) · Implementation Science · doi:10.1186/s13012-020-0977-0 · Cited by 418 · see citing works
Spreading and scaling up innovation and improvement
Greenhalgh, T., & Papoutsi, C. (2019) · BMJ · doi:10.1136/bmj.l2068 · Cited by 382 · see citing works
James, H. M., Papoutsi, C., Wherton, J., Greenhalgh, T., & Shaw, S. E. (2021) · Journal of Medical Internet Research · doi:10.2196/23775 · Cited by 164 · see citing works
Bulthuis, S. E., Kok, M. C., Raven, J., & Dieleman, M. A. (2020) · Health Policy and Planning · doi:10.1093/heapol/czz140 · Cited by 165 · see citing works
Côté-Boileau, É., Denis, J.-L., Callery, B., & Sabean, M. (2019) · Health Research Policy and Systems · doi:10.1186/s12961-019-0482-6 · Cited by 133 · see citing works
Scaling up public health interventions: engaging partners across multiple levels
Leeman, J., Boisson, A., & Go, V. (2022) · Annual Review of Public Health · doi:10.1146/annurev-publhealth-052020-113438 · Cited by 45 · see citing works
Gray, S. M., McKay, H. A., Nettlefold, L., Race, D., Macdonald, H. M., Naylor, P.-J., & Sims-Gould, J. (2021) · British Journal of Sports Medicine · doi:10.1136/bjsports-2020-102465 · Cited by 35 · see citing works
Key factors for national spread and scale-up of an eConsult innovation
Moroz, I., Archibald, D., Breton, M., Cote-Boileau, E., Crowe, L., Horsley, T., Hyseni, L., Johar, G., Keely, E., Burns, K. K., et al. (2020) · Health Research Policy and Systems · doi:10.1186/s12961-020-00574-0 · Cited by 24 · see citing works
Nguyen, M. X. B., Chu, A. V., Powell, B. J., Tran, H. V., Nguyen, L. H., Dao, A. T. M., Pham, M. D., Vo, S. H., Bui, N. H., Dowdy, D. W., et al. (2020) · Implementation Science · doi:10.1186/s13012-020-01020-z · Cited by 19 · see citing works
Di Ruggiero, E., & Edwards, N. (2018) · BioMed Research International · doi:10.1155/2018/1519402 · Cited by 16 · see citing works
Domingo, A., Yessis, J., Charles, K.-A., Skinner, K., & Hanning, R. M. (2023) · Implementation Science · doi:10.1186/s13012-023-01291-2 · Cited by 16 · see citing works
Bright, S., Moses, F., Ridout, A., Sam, B., Momoh, M., Goodhart, V., Smart, F., Mannah, M., Issa, S., Herm-Singh, S., et al. (2023) · Reproductive Health · doi:10.1186/s12978-022-01551-2 · Cited by 12 · see citing works
Domingo, A., Yessis, J., Zupko, B., McEachern, L. W., Valaitis, R., Skinner, K., & Hanning, R. M. (2024) · BMC Public Health · doi:10.1186/s12889-024-19391-z · Cited by 6 · see citing works
“Scale-up has been described as efforts to increase the impact of a successfully evaluated intervention to benefit more people and to foster maintenance and sustainability [22].”
BackgroundDesign Requirements for a Teledermatology Scale-up Framework
Walters, L. E., Scott, R. E., & Mars, M. (2018) · South African Computer Journal · doi:10.18489/sacj.v30i1.559 · Cited by 5 · see citing works
- Authors
- Barker, P. M., Reid, A., & Schall, M. W.
- Affiliations
- University of North Carolina at Chapel Hill (US)
- Institute for Healthcare Improvement (US)
- Corresponding author
- Barker, Pierre M.
- Venue
- Implementation Science
- Published
- 2015-12
- Volume
- 11
- Issue
- 1
- Pages
- 12-12
- ISSN
- 1748-5908 (ISSN-L)
- PMC
- PMC4731989
- OpenAlex
- W2272927507
- Cited by
- 400
- References
- 36
- Citations by year
- 2026: 32 · 2025: 48 · 2024: 55 · 2023: 44 · 2022: 41 · 2021: 54 · 2020: 37 · 2019: 38 · 2018: 26 · 2017: 21 · 2016: 4
- FWCI
- 31.01
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Implementation Science (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Carolina Digital Repository (University of North Carolina at Chapel Hill) (acceptedVersion)
- UNC Libraries
- Funders
- AcademyHealth
- Kaiser Permanente
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Global Health and Surgery
- Keywords
- complex health interventions, intervention adoption, Institute for Healthcare Improvement, Ghana, South Africa, Africa, health system improvement, intervention replication, evidence-based practice dissemination, health professions education
- MeSH terms
- Africa, Delivery of Health Care, Humans, Organizational Objectives, Models, Organizational, Evidence-Based Medicine, Capacity Building
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
