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How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda

Maryse Kok, Marjolein Dieleman, Olivier Onvlee, Susan Bulthuis, Thomasena O’Byrne, Samuel Amon, Justine Namakula, Kingsley Chikaphupha, Jana Gerold, Wesam Mansour, Joanna Raven, Jacqueline E. W. Broerse
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The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda.

The study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention.

A shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up.