Issues for scaling-up

In Institutional issues in scaling up programmes for meeting the health-related needs of the very poor, Kirk and Standing confirm that the scale-up potential of each of health assistance mechanisms will vary depending on the context. One key consideration is the institutional capacity required for implementation.

Other potential institutional obstacles to scaling up include prohibitive or unsustainable costs; the difficultly of using community-based targeting mechanisms (often used in the absence of other population-based data) on a larger scale; how to replicate effective partnerships between local constituencies and local government on a larger scale (what factors enable these partnerships to work in specific local contexts?); and how to minimise elite capture of targeted benefits in contexts where communities are highly differentiated.

The emphasis within international and national health policy on achieving the MDGs, and the relatively short timescale within which these goals must be realised, has created momentum around the need to scale up rapidly. Although rapid scaling up may be possible in some contexts, in situations where institutional capacity is weak expectations, of the scale and speed of scale-up need to be managed carefully. In these contexts, it may be more realistic to aim for gradual scale up, perhaps starting with a district, and then rolling out to cover a province or region.