Scaling up nutrition: what and how

Scaling up nutrition: what and how?

Stuart GillespieInternational Food Policy Research Institute

Addis Ababa, 5 June 2014

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Drawn from the original Transform Nutrition* evidence review:

Gillespie, S, Menon, P. and Kennedy, A (2014) “Scaling up impact on nutrition: what will it take and how will we get there?” forthcoming.

• Transform Nutrition is a consortium of five organizations led by IFPRI (including ICDDR,B, IDS, Save the Children, Public Health Foundation of India) that undertakes policy,

operational and evaluative research on nutrition-relevant actions with a particular focus on Ethiopia, Kenya, India, Bangladesh.

www.transformnutrition.org

Content

• Rationale and context• Definitions and concepts• Objectives• Methods• Results: 9 key elements• Conclusions

Rationale and context

• Aspiration and momentum….– SUN movement– Nutrition for Growth summit– Lancet series

• …..and ground-level realities– Coverage of quality nutrition-specific package poor where

most needed– Enhancing nutrition sensitivity of wider development

policies and programs remains challenging– Enabling environments: gap between political attention and

system commitment

In sum…

There is now a relatively strong consensus on what needs to be done, but much less is known about how to operationalize the right mix of actions in different contexts, how to do so at a scale that matches the size of the problem, in an equitable manner -- and how to do so in ways that link nutrition-specific and nutrition-sensitive interventions.

Scaling up definitions (examples)• “More quality benefits to more people over a wider geographical area more quickly, more

equitably, and more lastingly” (IIRR 2001)• “Identifying the most effective ways to channel additional resources in order to maximize impact

on the MDGs” (DFID 2013)• “To efficiently increase the socioeconomic impact from a small to a large scale of coverage

(World Bank 2003).• “Scaling up: the ambition or process of expanding the coverage of health interventions, but can

also refer to increasing the financial, human and capital resources required to expand coverage” (Mangham LJ et al. 2010)

• “Scaling up means expanding, adapting and sustaining successful policies, programs or projects in different places and over time to reach a greater number of people.” (Linn JF, Hartmann A 2008)

• “Deliberate efforts to increase the impact of successfully tested pilot, demonstration or experimental projects to benefit more people and to foster policy and program development on a lasting basis” (WHO, Expandnet 2011).

• “Scaling up is a process of expanding nutrition interventions with proven efficacy to more people over a wider geographic area that maintains high levels of quality, equity, and sustainability through multisectoral involvement.” (SPRING 2014)

Is it about making something bigger?....

….or about generating greater impact?

…can also be about change…

…or evolution…

Our working definition

“Scaling up nutrition refers to processes aimed at maximizing the reach and effectiveness of a range of nutrition-relevant actions, leading to sustained impact on nutrition outcomes”

Objective of the review

To synthesize what is known about scaling up in general from nutrition and other disciplines, in order to distill critical elements to guide actions that focus on scaling up impact on nutrition.

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Lancet (2013) framework (drawing upon Lancet (2008) and ultimately on UNICEF 1990)

Methods• Literature search (Google Scholar, PubMed, 2000-2013) • Keywords: scaling up, going to scale, diffusion, expansion,

mainstreaming, nutrition, health, agriculture, development.• Expandnet and Brookings bibliographies• Active consultation with key experts• Condensed to 42 papers

– Theoretical frameworks (24)– Program experiences (18)

• Long list of elements and features• Later condensed/merged to 9 key elements• In-depth case studies of 4 scaled up programs

Some frameworks….

Gillespie 2004

VISION/GOAL

Impacts (outcomes, benefits)

CAPACITY ELEMENTS

INSTITUTIONAL ARRANGEMENTS

QUANTITATIVE

FUNCTIONAL

POLITICAL

ORGANIZATIONAL

CDD ACTIVITIES

Sparks

CONTEXT;- local- wider

CONTEXT;- local- wider

WHO 2010

Chandy and Linn 2011

Results

9 elements are key to effective scale up

1. Vision and goal: where are we going?2. What is being scaled?3. Context/enabling environment4. Drivers and barriers5. Strategy, process and pathways6. Capacity to scale up7. Governance8. Financing scale up9. Monitoring, evaluation, learning, accountability

1. Vision: where are we going?

• Has the vision been clearly and collectively articulated with a compelling narrative that explains why it’s important, and how it can be attained?

• “Beginning with the end in mind” (WHO/Expandnet 2011)

• Appropriate indicators of impact and success• Vision determines metrics for accountability

2. What is being scaled?• A process, principle, project, technology, innovation, or

methodology?• Is there evidence of efficacy? Of large-scale effectiveness?• What works at small scale (drivers of success) may not

work at large-scale, and/or may change in the process of scaling.

• Interventions differ in scalability– relative advantage over existing products/practices– compatibility with existing values and practices– simplicity and ease of use– “trialability”– visibility of results– adaptability and “communicability”

3. Under what conditions?

• Macro-economic, social, economic, cultural, political and historical conditions and trends

• Institutional arrangements• Positive/enabling, neutral, negative/disabling• WHO (2013) review: disturbing conclusions• Community and household contexts• Implementation context– Stand-alone projects, integrated programs

Simpler intervention Complex interventionSimpler context

Vit A supplementation through campaign.

Distribution of micronutrient powders to homes through NGO platform

Complex (multi-component) behavioral change communication intervention through community-based nutrition-focused NGO program platform.

Agricultural diversification intervention through nutrition-focused NGO program platform

Complex context

Vit A/iron-folate pills/calcium supplements through multi-purpose, multi-tiered government health system

Integrated complex behavioral change communication, micronutrient supplementation and agricultural extension intervention through women’s self-help groups and links with government health systems.Integrated continuum of care (community to facility and back to community) for screening, identification, referral, treatment and follow-up and management, of severe acute malnutrition through multi-purpose, multi-tiered government system

Illustration of the intersection of intervention complexity with implementation context complexity

4. Drivers and barriers

• Internal and external• Actors/stakeholders– Leaders, champions, policy entrepreneurs

• Government owndership• Incentives/disincentives

5. Scaling up strategy• What will be done, and how will it be done?• Theory of change• Processes and pathways (following Uvin 2000)

– Quantitative: intervention expands in size, geographical base, or budget (also referred to as ‘scaling out’);

– Functional: increases in the types of activities and integration with other programs;

– Political: increases in political power and engagement;

– Organizational: increases in organizational strength/capacity. • Simultaneous/sequential• Purposive/emergent

A learning process (Korten 1980)

6. Capacity to scale up

• Defined by level…– Individual, organizational, systemic

• …..and by purpose– Strategic and operational capacities are key– Capacity to make demands

• Poor quality nutrition service delivery often coincides in time and space with outdated, impractical and misaligned nutrition training programmes and academic curricula.

Systemic capacity strengthening: a hierarchy of needs

enable….. require…..

ToolsSkills

Staff and InfrastructureStructures, Systems and Roles

Brough and Potter (2004)

e (2001)

Gillespi

e

(

e (2001)

7. Governance

• Structures and systems that underpin processes of scale up

• Horizontal (cross-sectoral)• Vertical (national to local) coherence• “Scaling down” (of central power, resources) often

needed for sustainable scale up.– e.g. Thailand in 1980s

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Horizontal and vertical coherence

Vertica

l coordi

nation

high

Good cross-sectoral coordination&

Good cooperation between centre and local levels

low

low high

Horizontal coordination

Anticipating and resolving trade-offs

1. Ease of scaling vs need for scalingReaching “unreached” essential but difficult

2. Speed vs. sustainability“Alone, I go faster; together, we go further”.

3. Quality vs. quantity/coverage– e.g. India (Maharashtra)

8. Financing scale up

• Adequacy– To reach all those who need, and who can benefit

• Stability– Building capacity, evidence, experience

• Flexibility– To permit adaptive, devolved management, local innovation

and learning• Other challenges– Cost of enhancing nutrition sensitivity?– Cost of building and sustaining enabling environments– Who pays?

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Resources for nutrition (Gillespie et al 2013)

Country type

High-burde

n countries

Create budget lines, Increase commitments,

Find nutrition sensitive opportunities

Fortification,Logistics,

Local innovationMarket purchases

Donor

countries Increase commitments,

Create incentives that leverage high burden

Risk sharing and pooling,Innovation start ups Ethical trading

Public-only Private-public networks

Private-only

Resources for Nutrition

9. M&E, learning, accountability

• Limited evaluations of large-scale programs– Coverage, quality, equity, sustainability and outcomes– Impact pathways (demonstrating impact and showing

how it was achieved)• Even fewer evaluations of scaling up processes

and approaches• Investment in implementation research is needed• Strengthening institutional M&E capacity– E.g. Mexico, Thailand, Bangladesh

Conclusions• Need for greater coherence and consistency with regard to the

“ends and the means” of scaling up – its scope, purpose and its essential processes.

• 9 elements need to be brought together, enabled or activated• Go beyond scaling up nutrition-specific interventions and cultivate

leadership and enabling policy environments.• Walking the talk -- without a scale up in strategic and operational

capacities for planning and action at different levels – whether designing or implementing nutrition-specific interventions, or maximizing the nutrition-sensitivity of other sectoral actions – it will not be possible for the current global momentum to be translated into sustainable impact on the ground. Short to medium term project funding cycles of 3-5 years will not be enough for this – what’s needed is a 10 year investment roadmap.

Thank you

Acknowledgements:Transform Nutrition/DFID (evidence review)

A4NH and USAID/SPRING (conference participation)

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