Scaling-up Innovations in Public Health Nancy Edwards Professor, University of Ottawa, Scientific Director, Institute of Population and Public Health Canadian Institutes of Health Research

Canadian Institutes of Health Research Institute of Population and Public Health Health Equity Matters

Approach Reviewed all titles from assembled literature to identify relevant studies Identified public health “scenarios” that reflect different classes of innovation Limited search for recent articles/reports (including review articles and case studies) pertinent to scenarios

Scaling-up Common Elements of Definitions Series of processes to introduce innovation(s) with demonstrated effectiveness Processes involve organizational and/or political intentionality Aim for sustained improvements in coverage of, and equitable access to the innovations Require program delivery structure/strategy

Classes of Innovation Discrete Multi-component and multi-level Paradigmatic

Classes of innovation Class of Innovation Characteristics Discrete (e.g. vaccines, fluoride in drinking water) Well-defined, specific dose and delivery parameters, demonstrated efficacy and effectiveness, packaged for ease of delivery. Multi-component and multi-level (e.g. tobacco control and childhood obesity prevention strategies) More complex, less prescriptive, less structured than discrete innovations. Program components may be required to act synergistically to yield their intended benefits; require adjustment to both characteristics of target population and dynamic implementation contexts. Paradigmatic (e.g. determinants of health approach, health in all policies) Involve a major conceptual shift in the way we think about issues and their solutions. Systems-wide approach and complex set of partnerships.

Key Factors Limiting Scale-up (1) Underestimating type and quantity of resources required –Implementation capacity - human, financial, infrastructural investments –System absorption capacity – governance, administrative, accountability and financial systems Political and/or policy naivety –Not understanding actors involved – failure to get issue on policy agenda –Lack of long-term political commitment –Vested interests

Key Factors Limiting Scale-up (2) Lack of attention to potential for scaling-up and sustainability during initial testing of innovation Inattention to demand side of scale-up –Push versus pull Over-emphasis on either vertical or horizontal spread of innovations

Key Factors Limiting Scale-up (3) Inattention to temporal dimensions of scale-up –Spatial dimensions – coverage, reach, availability and accessibility of services –Temporal dimensions – differential rate of change at each system level

Public Health Scenarios H1N1 vaccination Tobacco control Policy change and built environment

H1N1 Key Learnings preparing for a range of potential epidemic scenarios deploying an ethical and cost-effective approach to distribute a limited resource (vaccine and tamiflu) media rapidly increased the demand side for vaccines scale-up constrained provision of other essential public health services Highlighted importance of a systems approach for effective scale-up

H1N1 Research Questions What gets scaled-down and what are the short and long-term impacts of scaling-down programs when surge responses are required to deal with a public health crisis? What are the critical elements required for components of a system (both those under the authority of health ministries and those outside their authority) to work most effectively as a responsive and adaptive system for rapid scale- up?

Tobacco Control Key Learnings government commitment at all levels essential to resource a comprehensive and long-term multi- faceted tobacco control strategy coalitions and alliances maintained momentum towards tobacco reduction goals monitoring and evaluation systems informed decisions about progress (e.g. shifts in patterns of tobacco use and types of tobacco used) constant vigilance has been required to identify counter measures by the tobacco industry

Tobacco Control Research Questions What can be learned about successful efforts to scale-up the adoption of lifestyle changes by the private sector within and across jurisdictions? How do national and international conventions on product control (e.g. control of tobacco products) exert their influence within and across jurisdictions?

Policy and built environment Key Learnings enduring and omnipresent influence of the built environment on all types of human activities other sectors play key role in planning, designing and constructing the built environment built environment exemplifies historical and structural influences that create system rigidity, potentially reinforcing inequities across social strata

Policy and built environment Research Questions Does modeling the projected scaled-up impact of the built environment shift decisions about options for land use, urban design, transportation corridors or housing developments?

Highlights - What we know Scaling up involves a complex chain of pathways, and adaptive changes to the innovation in a dynamic context Many factors external to the innovation influence scale-up including system absorption capacity, governance mechanisms, partnerships, political will, leadership, and financial accountability structures Policy windows of opportunity may set the stage for initiating scale-up change processes, while alliances may help maintain momentum for longer-term scale-up Both horizontal and vertical dimensions of scaling-up are important

Highlights - What we don’t know Approaches to scale-up that optimally strengthen equity, while improving overall health status. Direct and indirect costs of scale up. What is required for initial versus sustained scale-up. Comparative effectiveness of approaches to scaling up-across classes of innovations and under a range of contextual conditions (governance, financing, leadership, political support). Intersection of scaling-up and scaling-down processes.

Recommendations - Highlights A typology for classes of innovation in public health requires further development. A framework is needed for the contextual analysis of scale-up. Research on the scale-up of public health innovations should include equity outcomes. Temporal dimensions of scaling-up require further study. Identify what monitoring and feedback systems are needed to better capture scaling-up processes and integrate these systems into the planned scale-up of large initiatives. De-scaling - how to remove innovations that have already gone to scale - warrants more attention.