Introduction

This discussion paper defines "scale-up" and illustrates practitioners' experiences with nutrition scale-up. Since efforts for scale-up fail without fully considered or planned approaches, the paper concludes with suggestions for designing and implementing programs that work at scale and, more importantly, lead to at-scale impact on nutrition outcomes. Proliferation of evidence on strategies for combating malnutrition has focused attention on the need to scale up nutrition actions and programs. The 2008 series on maternal and child undernutrition in The Lancet called for 99 percent coverage of 8 core interventions in countries with high burdens of undernutrition.¹ The 2013 update to the series recommended 10 interventions at 90 percent coverage.²

To assist in the scale-up of such nutrition strategies, a number of initiatives have been launched, including the Scaling Up Nutrition (SUN) Movement. To date, 55 countries have signed on to the core SUN principle: multi-sectoral commitment to increasing coverage of nutrition-improving interventions.³ In addition, the U.S. Agency for International Development (USAID) developed the Multi-Sectoral Nutrition Strategy 2014–2025, which aims to "scale up effective, integrated, nutrition-specific and nutrition-sensitive interventions, programs, and systems across humanitarian and development contexts."⁴

To inform the ongoing discussion, the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project conducted a literature review and interviewed nutrition practitioners.* The SPRING literature review⁵ pulled from academic and programmatic discussions of scale to define types and components (Figure 1) and propose a definition (see "What is scale-up?" box). The process of scale-up varied, and at least three approaches can be identified as being useful:

 

• Vertical scale-up: An institutional process that broadens the range of stakeholders from local to national or even to global levels and from individuals to institutions and governments.⁶
• Horizontal scale-up: This approach expands coverage or programming to new end users.⁶
• Functional scale-up: This approach increases the scope of the activity, possibly through multi-sectoral actions.⁷

The components essential to and held in common by efforts to define and measure scale-up include efficacy, sustainability, equity, and quality. These components and approaches of scale can be sought separately or jointly, depending on need and circumstance. However, achieving impact at scale will likely require all three approaches, all four components, and an in-depth understanding of how food, care, and health systems interact.⁸

Figure 1: SPRING's Conceptual Framework for Scale-up

 

Lessons from Scaling Up Nutrition Programs

 

SPRING asked representatives of USAID-funded nutrition projects to share how they plan and implement nutrition scale-up. Key lessons from these interviews are summarized below with illustrative quotes from interview participants.

I. Multi-sectoral action is often overlooked during scale-up.

Practitioners often emphasize the importance of multiple sectors working together to expand nutrition programming. However, a focus on increasing coverage through vertical programs or a single sector can result in projects overlooking this functional scale-up approach. Multi-sectoral coordination for nutrition is not generally a priority when implementers must collaborate across sectors without historical precedent, sector-specific objectives for nutrition, or incentives for collaboration.

II. Quality is at odds with a rapid expansion of coverage.

Nutrition projects are often expected to expand rapidly. Interviews with USAID project staff confirm that their focus has been primarily on horizontal scale-up, with reporting often focused on numbers of people or institutions reached but not on the quality of that coverage. Across the nutrition field, this coverage-quality conflict needs to be addressed, so a rush to scale does not detract from overall nutrition outcomes.

III. Achieving equity at scale is challenging.

Projects that specifically target vulnerable populations consider equity to be an overarching part of both their programming approach and strategies for scaling up. However, projects without a specific mandate to target vulnerable populations often fail to provide coverage to those who are especially hard to reach. Discussions with implementers revealed that projects may lack the flexibility, time, or resources necessary to accommodate the specific needs of vulnerable populations. As a result, some interventions are scaled up to reach everyone, whereas others focus only on the most vulnerable populations.

IV. Guidance is needed around pathways to sustainability.

Sustainability is often included in definitions of scale-up. Implementing partners describe two main approaches to improving the sustainability of interventions and their outcomes. An institutions-focused approach aims at improving capacity from the national level all the way to district, facility, and community levels. Broadening the number of stakeholders from the local level to institutions and the national government – that is, vertical scale-up – is perceived as contributing to sustainability. The other approach focuses on institutionalizing norms and behaviors at community or household levels, with the belief that behaviors will persist even in the absence of continuing interventions. Efforts are underway to examine the ability of national multi-sectoral nutrition plans and interventions to sustain changed behaviors at scale.^{3, 15, 16, 17}

V. Efficacy and cost-effectiveness work differently at scale.

Many projects are thoughtfully designed to include evidence-based interventions. However, interventions that have proven to be efficacious or cost-effective in one setting may not necessarily perform the same way at scale. As implementation or targeting changes at scale, so can efficacy and cost-effectiveness. Projects face a dearth of evidence and guidance on which nutrition programs or approaches can be effectively scaled up.

VI. Indicators should reflect a more nuanced understanding of scale-up.

Current scale-up indicators track people or institutions reached over time thus reflecting outputs of a horizontal approach, whereas indicators of impact at scale remain difficult to measure or attribute to a project. Performance monitoring plans rarely include indicators that track the scale-up process. Existing indicators encourage projects to focus on numbers without reflecting on context, diffusion of practices, or barriers to long-term impact.

Looking Ahead

As indicated by these lessons and in the wake of the USAID Multi-Sectoral Nutrition Strategy's call to "scale up effective, integrated nutrition-specific and -sensitive interventions, programs, and systems," it is time to evaluate current efforts to scale up nutrition programs. How USAID understands, defines, and holds projects accountable for scale-up significantly affects project implementation. Three priorities emerge for impro

Build consensus around a definition of scale-up.

A shared vision of scale-up among donors, implementing agencies, and country governments is essential if projects are to prioritize, implement, and develop approaches to reach scale in the local context. This vision should incorporate the emerging understanding of scale-up as a multifaceted process rather than as a static state. It must also take into consideration all the components (i.e., efficacy, equity, quality, and sustainability) and approaches described above to positively influence nutrition outcomes. Interventions and programs focused solely on increasing coverage will not have the potential to achieve long-term nutrition goals. With the attention given to scaling up nutrition in the USAID Nutrition Strategy, missions would be well-served to take leadership and facilitate discussion among partners on the definition of scale-up and a coordinated approach to it.

Attend to the process of scale-up.

Developing and promoting process or output indicators allows programs to understand if they are making progress toward scale-up and to inform ongoing adjustments. These indicators may include the number of children under 2 or pregnant women reached with distinct nutrition interventions; the number of mothers or caregivers who participate in a minimum number of IYCF counseling sessions; and the number of individuals who receive nutrition-related professional training. Projects may develop new or adapt existing process or output indicators to reflect efficacy, to track equity (e.g., disaggregate by wealth quintile), to monitor quality, and to define and measure sustainability in the context of the program. Efforts in developing such indicators should be documented and shared with other practitioners to advance the efforts of the nutrition community.

Facilitate learning and experience sharing.

The multi-sectoral nature of nutrition and the need for coordination, in addition to the inconsistency in definitions of scale-up and approaches to it, highlight the importance of sharing experiences and what has been learned. Sufficient understanding does not yet exist of which interventions are most effective at scale in different contexts, and many non-health sectors are unsure about which nutrition outcomes they should hold themselves accountable for achieving. However, projects also reported some best practices for nutrition programming scale-up, including flexibility of the project to context, partnerships or collaboration with governments, and provision of multiple messages through multiple channels. Implementers need to understand both how to design for the process of scale-up and how to access examples of program successes and challenges in approaching and implementing scaled-up nutrition programs.

Key Considerations for Scaling Up Nutrition Programs

The following list of questions can be used to design, plan, and achieve impact on nutrition at scale. While every situation will address nutrition scale-up in a slightly different way, answering these questions can identify possible barriers to success and highlight areas for strengthening implementation.

Citations and Resources

This list includes references for the documents cited in this brief. In addition, we recommend those items in bold font for readers interested in learning more about nutrition scale-up.

• Bhutta, Z.A., Ahmed, T., Black, R.E., et al. 2008. "What Works? Interventions for Maternal and Child Undernutrition and Survival." The Lancet 371, no. 9610: 417–40.

• Bhutta, Z. A., Das, J.K., Rizvi, A., Gaffey, M.F., Walker, N., Horton, S., Webb, P., Lartey, A., and Black, R.E.. 2013. "Evidence-Based Interventions for Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost?" The Lancet 382, no. 9890: 452–77.

• SUN. 2014. "SUN Countries—Scaling Up Nutrition."

• U.S. Agency for International Development (USAID). 2014. "Multi-Sectoral Nutrition Strategy 2014–2025 [PDF, 1.3MB]." Washington, D.C.: USAID.

• D'Agostino, A., Wun, J., Narayan, A., Tharaney, M., and Williams, T.. 2014. Defining Scale-Up of Nutrition Projects [PDF, 510KB]. SPRING Working Paper. Arlington, VA: SPRING Project.

• Menter, H., Kaaria, S., Johnson, N., and Ashby, J.. 2004. "Chapter 1: Scaling Up." In Scaling Up and Out: Achieving Widespread Impact through Agricultural Research, edited by Douglas Pachico and Sam Fujisaka, 9–24. Cali, Colombia: Centro International de Agricultura Tropical (CIAT).

• Hartmann, A., and Linn, J.. 2008. Scaling Up: A Framework and Lessons for Development Effectiveness from Literature and Practice. Wolfensohn Center for Development Working Paper 5. Washington, D.C.: Brookings Global Economy and Development.

• SPRING. 2014. Systems Thinking and Action for Nutrition: A Working Paper. Arlington, VA: USAID/Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.

• CORE Group. 2005. "'Scale' and 'Scaling-Up': A CORE Group Background Paper on 'Scaling-Up' Maternal, Newborn, and Child Health Services." [PDF, 82KB]

• Hodgins, S. 2013. "Draft Guidance on Scale-Up." Washington, D.C.: Maternal and Child Health Integrated Program (MCHIP).

• Linn, J.F., ed. 2012. "Scaling Up in Agriculture, Rural Development, and Nutrition." [PDF, 2.9MB] Washington, D.C.: International Food Policy Research Institute.

• Milat, A.J., King, L., Bauman, A.E., and Redman, S.. 2013. "The Concept of Scalability: Increasing the Scale and Potential Adoption of Health Promotion Interventions into Policy and Practice." Health Promotion International 28, no. 3: 285–98. doi: 10.1093/heapro/dar097.

• Victora, C.G., Hanson, K., Bryce, j., and Vaughan, J.P.. 2004. "Achieving Universal Coverage with Health Interventions." The Lancet 364, no. 9444: 1541–48.

• World Health Organization (WHO), and ExpandNet. 2009. Practical Guidance for Scaling Up Health Service Innovations [PDF, 961KB]. Geneva, Switzerland: WHO.

• Alive and Thrive. "Alive and Thrive," 2015.

• SPRING. "Infant and Young Child Feeding Trainings." SPRING, 2015.

• ———. "Pathways to Better Nutrition Case Study Series." SPRING, 2015.

This Technical Brief will be periodically updated. Comments from readers are welcome to Leslie Koo, especially comments to help clarify the information provided or where additional information may be useful. (Last updated February 23, 2016)

This discussion paper was  produced for the U.S. Agency for International Development, with the support of the Strengthening Partnerships, Results, and Innovations Globally (SPRING) project.

*In January 2014, USAID asked the SPRING project to validate the proposed definition and framework for nutrition-programming scale-up to ensure that the findings from the literature reflected programming's current state. Project documentation review and interviews with staff from 11 projects validated the definition and framework while highlighting that understanding or definitions of scale-up do not always stay constant within projects.