In the context of COVID-19, it has become apparent that health services need to be flexible and speedy to meet the rapidly changing needs of the population. Immunization and healthcare services in LMIC face several challenges to find new ways to achieve more efficient health systems and services. In recent years, donors and partners have been keen to support rapid innovations, yet there was no clear strategy on how innovations should be scaled up to maximize benefits of successful innovations.
Innovation scale-up is a challenge
GaneshAID has witnessed unfortunate situations where donors investing in novelties but then dropping support required for the long-lasting innovation adoption, sustainability and deployment to a larger number of users. Therefore, GaneshAID aims to support all stakeholders and partners in developing early innovation strategic planning to envision the innovations beyond experimental phase. It is strongly recommended that from the design phase, health system/service innovations are planned with successful scale-up in mind.
| Scaling up is defined here as efforts to increase the impact of innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and programme development on a lasting basis. | – Definition of scaling up innovations according to ExpandNet, WHO.
Innovation scaling up is a major challenge faced by many developing country governments, donors, and implementing agencies. Impacts of new solutions/approaches are constrained unless they have stronger policy and program support. Likewise, demonstrated innovations cannot simply be delivered with the expectation that they will, without any scale up plan, automatically become part of the routine programme implementation. The scale up process needs intentional forces to adopt policy and programme development on a lasting basis. In this way, the impact of successfully tested pilots will be augments and more programs, health workers will benefit from innovations.
GaneshAID, together with Ministries of Health, envision need-based innovations grounded on organizational and individual adaptive changes with a legal framework and clear methodology for integrating innovations into the different health program system and mode of operations. If not anticipated at an early stage, the necessary actions and resources are not available and very often, innovations cannot move beyond the pilot phase to help beneficiaries on a larger scale.
Health innovation implies in-country change management
With each major and minor change, resistance is bound to appear. Even though the innovation brings desirable changes for the health and immunization systems, they are time-consuming to implement and require substantial resources. Additionally, the health system has a high level of inertia and a low level of perceived motivation for change. Changes in way of thinking or working that health innovations bring about should be supported and approved by Governments.
The scale-up team must anticipate and plan mechanisms to accompany the adoption of innovations through Organizational Development capacities. Organizational Development is a critical and science-based process that helps organizations build their capacity to experience changes and achieve greater effectiveness by developing, improving, and reinforcing strategies, structures, and processes.
Therefore, participation in the scaling up of innovation should extend to all levels of the health system: frontline health workers and immediate supervisors, national health programs. Such process should be supported resolutely through continuous dialogue with decision-makers. Stakeholder engagement outside the health system is also crucial when considering other sectors including ministry of planning, finance, or private sectors. The participatory approach mobilizes a greater number of participants in the scaling-up process and ensure that local needs are met with a sustainable adoption of the innovation by decision-makers and users in a country. Most importantly, end-Model Of Organizational Development adapted from Middlemist and Hitt (1988) must be supported so that they can contribute to the scaling process.
GaneshAID applies a participatory process involving key stakeholders, partners, and donors to ensure the potential for future large-scale implementation of innovations.
Model Of Organizational Development adapted from Middlemist and Hitt (1988)
Advocacy for innovations scale-up strategies
Because of our strong engagement to transform health and immunization services in LMIC, we cultivate innovation as a strategic medium. We encourage all organizations to support innovative thinking and processes to save more lives around the world. We raise our voices for the essential needs for multisectoral supports to transform small-scale innovation into large-scale solutions and sincerely hope that they will be heard by the international community and donors.
Successful Scaling up: Call to action
Based on our experiences in Africa and Asia as well as the orientations of the ExpandNet model, GaneshAID recommends the following actions:
- Co-design with Ministry of Health and implement the pilot project with the objective of expansion.
- Build multiple partnerships and long-term funding – these requirements are often overlooked by donors, national stakeholders, and development partners.
- From the beginning, collaborate with stakeholders to clearly define innovation, have a concrete vision of successful scaling, and identify specific indicators as well as benchmarks.
- Find the right balance between innovation institutionalization and expansion.
- Focus on monitoring, evaluation and learning during the expansion and necessary continuous adaptations.
- Before and throughout the scaling process, identify necessary adjustments and mid-term corrections in new sites, maintain momentum and accountability as well as strengthen strategic planning skills among stakeholders.
- When adaptation is needed, replicate the key features of the successful pilot project when scaling up (i.e. research-based planning, a systems approach, partnership with appropriate organizations, a diversity of stakeholders and providers, and communication with decision-makers).
- At the operational level, define indicators for access to the new solution and its integration into health programs in the context of the health and immunization delivery system.
- Involve multiple partners in research to document the progress of the innovation scale up.
- Produce up-to-date and relevant data for stakeholders with diverse needs.
GaneshAID’s Innovation Scale-up Framework
GaneshAID envisions innovation scale-up process as a mechanism to increase the number of users/beneficiaries in local conditions, to study the innovations’ results and impacts in terms of increased performance health workers (knowledge and skills), thus consequently leading to the improved health service delivery. GaneshAID’s technical support focuses on organizational development that addresses necessary health service transformation – e.g. reorganizing immunization activities with skilled vaccinators to cope with the Covid-19 pandemic. We support countries in formulating appropriate strategy to introduce planned change needed to scale up tested innovations. This is critical to assist the health systems with managing the turbulent environment so to save more lives.
Any scale-up scenario implies a scale up strategy that covers six key components:
Scale-up strategy – 6 key components for VacciForm (Benin)
These components are required to ensure:
- Legitimizing the innovation as the approved change to improve health services/systems.
- Building trust in the innovation benefits among health workers for facilitate health services performance.
- Advancing national expertise and skills required for effective use of the innovation, e.g. digital technologies.
- Adapting the organization and people to the organizational change for development.
- Mobilizing financial support to implement the scale-up strategy with specific change management effort to adopt, sustain, and deploy the innovation to a larger number of users.
- Monitoring progress against the plan and advancing learning and evaluation to deepen knowledge of benefits and risks at initial stages of the use of new health solutions.
Benin case study: Innovation scale-up for maintaining routine immunization
In Benin, one of our innovations to improve routine immunization during pandeic – VacciForm – has positive but limited test results in terms of number of testers (26 in 24 immunization sites) and duration (15 days). Therefore, it was required to undergo a validation phase prior to larger scale up. The validation or replication phase considers a restricted number of health department and health zones, representing 10-20% of the immunization staff depending on the decision of the Ministry of Health/EPI: 360 to 720 vaccinators to be selected by the national EPI team.
As per the 2018 SARA Survey, immunization services are delivered in 73% of the 966 public health centers in Benin. Immunization services are integrated into healthcare activities but there are no staff dedicated to immunizationso this task is often passed to nursing assistants. In fact, training needs for immunization activities are not adequately covered. Only 62% of the health centers had staff trained on EPI activities with a variation from 12% in Ouémé (South Health Department) to 87% in Alibori (North Health Department).
The scale up phase considers the health workforce involved in EPI activities in Benin as per the following:
Health workforce at levels
Vacciform replication scale-up
Senegal case study: innovation scale-up for EPI supportive supervision 2.0
Coach2PEV, our innovation on supportive supervision and performance coaching, has been tested by EPI staff (Senegal) in local operation conditions up to the immunization service point. The results revealed that the new approach of supportive supervision combining performance coaching and a mobile app complies with EPI’s requirements. The usability by testers has been verified with statistics of various functionalities tested by users, a set of bugs were identified with immediate correction and a mitigation plan. While positive testing results from both pilots, the duration of the tests was insufficient to measure the actual impacts of the innovations.
The overall satisfaction of testers was measured through an online survey, demonstrating the high level of satisfaction and acceptance of supervisors and supervisees.
Phase 1: Coach2PEV replication
To validate the feasibility of the use of Coach2PEV and its acceptance as an appropriate supportive supervision model, a replication of the pilot should be implemented on a greater number of sites to serve more users/EPI staff in the field.
Indeed, Coach2PEV has already been tested with a limited number of pilot sites in the health districts of Dakar Center, Dakar West, Kaffrine and Touba, over a period of 4 months. The results obtained demonstrate that the performance coaching model – tested in real conditions – is suitable for the supportive supervision of the EPI in Senegal and is recognized as an advantage compared to the usual practice of traditional supportive supervision. GaneshAID supported the required enhancements of Coach2PEV for a suitable model validation test.
This test made it possible to verify that Coach2PEV as an innovation holds the “CORRECT” determinants of the scaling up:
|Credible as it is supported by the leaders of the EPI and the prevention department
|Observable to ensure that end users can see the results in practice
|Relevant to a persistent problem
|Relative advantages over usual supportive supervision practices, so that potential users are convinced that the costs of implementation are outweighed by the benefits
|Easy to install and use
|Compatible with the existing values of users, and whose standards and structures are adapted to EPI practices
|Testable before full user adoption and before results are produced
The EPI coordination decided to proceed with the replication of Coach2PEV in all the vaccination units of the 3 medical regions and 4 health districts of the pilot test. This represents 69 vaccination units – involving 14 coaches and 71 coachees/investigators in 16 health centres and 56 health posts.
The replication of the use of innovation in a real situation by 85 EPI staff at the health district, health center and health post levels will enable the validation of the Coach2PEV model for supportive supervision.
Pilot sites (in white) and Coach2PEV replication sites
Phase 2: Coach2PEV expansion
The replication of Coach2PEV to a higher number of beneficiaries was necessary to validate the innovation as an appropriate EPI supportive supervision approach. Likewise, during the replication, scale-up team documents the challenges and factors of success for the adoption of Coach2PEV by users. Thus, the scaling-up approach will respond to all challenges by specifying the conditions required for the users’ adoption of Coach2PEV.
It is also necessary to organize the scaling process as follows:
- The various actors who can help scale-up will be gradually involved during the expansion strategy to expand the number of individuals and organizations at the district, health center and health post levels. They will ensure the initiatives inthe current and future scaling. This will involve disseminating the shared vision of Coach2PEV innovation and the process of scaling up among stakeholders and partners, such as planning the creation of teams of coaches at regional and health district levels.
- The leadership of the EPI Prevention/Coordination Department is central to ensure that Coach2PEV will be integrated into the EPI system.
- The Coach2PEV solution must be scalable and adaptable to the needs and context of the Senegal EPI.
- Extend innovation gradually by phase. The advantage is to be able to implement many mandatory actions to put in place the necessary technical and institutional capacities and ensure the sustainability of the solution. Faster scaling up requires more financial and human resources.