Las nuevas líneas de orientación del proyecto de reforma agraria

Successfully taking a high quality intervention to scale, as perhaps the ultimate goal of implementation science, is predicated in part on intervention effectiveness (demand, delivery and outcomes, and the adaptability of efficacious interventions to real world constraints), as well as political priority setting. The term “scale-up” (sometimes referred to as “going to scale” and “at scale”) is widely used in public health literature. But there is neither an agreed definition nor framework for studying scale-up in international settings (67, 89-92). Scale-up has been used to describe the increased coverage of tested/effective interventions to benefit more people at a larger or national scale (90). It has also been used to describe both the purpose (to increase coverage, as well as the process of expanding interventions), the inputs required (financial or human resources), or the actual policy or strategy for expansion (67, 91). Attention, however, appears to have focused more on achieving high coverage rates than on the process of scaling-up (93). Perhaps the following general definition by Mangham and colleagues is most useful, as it is used by a number of researchers: “the ambition or process of expanding the coverage of health interventions” (67).

2.2.1 Pathways for Going to Scale

Although there is no single agreed upon approach for expanding the coverage of health interventions, a number of different pathways can be employed. “Quantitative” or “horizontal scaling-up” refers to an expansion in size, geographic base, and/or budget (62, 64). Another pathway is diversification—adding new interventions to existing innovations (also called “functional”), and a third is policy or legal actions, which is also referred to as “vertical scale-

up” (62, 64). A cascade or phased approach is yet another pathway, which entails tailoring to the local situation, and integrating into an existing delivery mechanism (3, 59, 89). Two more

processes are: “1) organizational, which refers to improving organizational strength and capacity; and 2) political, which refers to political power and engagement with wider political processes” (62). Additional approaches are recommended to achieve scale: “task shifting within the public sector and increasing the capacity and service delivery of community health workers (67),” and using the private and NGO sectors for service delivery (56, 58, 67).

For complementary feeding, a four-part approach for “disseminating, replicating, and scaling-up” improved programs is drawn from four countries’ experience: 1) engendering political commitment, government ownership, and partner support at all stages; 2) evidence- based program planning by employing contextualized practices and using a theory of change; 3) program implementation using doable, locally-relevant, action-oriented messages and foods, strengthening the health system to provide sustained support to families, and building capacity of and utilizing actors from all sectors; and 4) program evaluation to assess and improve quality through processes and impact studies (60).

Nutrition interventions have tremendous diversity in strategy/product as well as context, both of which can be either simple or complex (62). The appropriate scale-up strategy depends on the intervention characteristics—simple and applied in a specific setting, or complex and implemented across a system (92, 94). Interventions can also be characterized as complex, meaning they can be product or service intensive (67). Furthermore, they can be delivered through different—and sometimes multiple—channels, such as clinical, community-based preventive or promotional, mass media, or legislative, all of which affect the scale-up strategy (56, 95).

2.2.2 Factors for Effectiveness

Drawing from the literature, factors of effective scale-up efforts common across case studies are “strong leadership, effective management, realistic financing arrangements, country ownership, and technical innovation” (67, 93). Further, approaches that build partnerships among stakeholders at various levels, from community members to policy makers, to researchers and technical experts, appear to have been more successful than those that do not (93). Experience with nutritional interventions in Bangladesh, Ethiopia, and Vietnam confirm these findings, highlighting three core strategies for scaling-up and maintaining quality: “1) using national-level coordinating and information exchange mechanisms to catalyze action in a harmonized way; 2) providing institutional support and sharing ownership with carefully selected implementing partners to facilitate sustainability; and 3) generating and disseminating evidence regularly through routine program monitoring, rigorous evaluation, documentation, and stakeholder forums” (56).

Experience from a community-based nutrition program in Thailand found that a dual approach encompassing action at policy and community levels to be key. Facilitators of success also entailed capitalizing on cultural values regarding the care of children, raising community awareness of the problem and presenting a solution, using indicators for multisectoral efforts, focusing programming on targeted geographic areas, and developing human, financial, and management resources (96). Many of these attributes were also identified by a 2015 scale-up nutrition literature review, which synthesized articles about theoretical frameworks and programmatic experience with scale-up into nine key elements (62). As presented here, these elements are further summarized into seven: 1) having a clear vision/goal, with metrics, for large-scale impact, and framing why the issue is important and how it can be addressed; 2)

identifying clearly what is being scaled, the evidence of effectiveness, and the scale-up strategy, processes and pathway(s); 3) understanding well the socio-political environment, such as the degree to which there is national ownership and commitment, political support for a coordinated multisectoral response and supporting governance structures, and champions to catalyze and sustain efforts, or systematic incentives for change; 4) establishing governance mechanisms for creating and managing horizontal and vertical actions; 5) developing strategic and operational capacity to plan, implement, monitor, and evaluate the scale-up process; 6) ensuring financial resources are available for capacity building and going to scale; and 7) developing monitoring and evaluation (M&E) to support accountability and generate data for course correction and evidence of impact (62).