The document discusses key elements for effectively scaling up nutrition programs to have a greater impact. It identifies 9 critical elements: 1) a clear vision and goals, 2) defining what is being scaled up, 3) understanding the enabling environment and context, 4) identifying drivers and barriers, 5) developing a scaling up strategy, 6) building capacity, 7) establishing governance structures, 8) securing adequate and flexible financing, and 9) conducting monitoring, evaluation and learning. The document argues that these elements must be coordinated to scale up both nutrition-specific interventions and enable broader enabling environments and policies to maximize nutrition impact.

1. Scaling up nutrition:
what and how?
Stuart Gillespie
International Food Policy Research Institute
Addis Ababa, 5 June 2014

2. Drawn from the original Transform Nutrition* evidence review:
Gillespie, S, Menon, P. and Kennedy, A (2014) “Scaling up
impact on nutrition: what will it take and how will we get
there?” forthcoming.
• Transform Nutrition is a consortium of five organizations led by IFPRI (including
ICDDR,B, IDS, Save the Children, Public Health Foundation of India) that
undertakes policy, operational and evaluative research on nutrition-relevant
actions with a particular focus on Ethiopia, Kenya, India, Bangladesh.
www.transformnutrition.org

3. Content
• Rationale and context
• Definitions and concepts
• Objectives
• Methods
• Results: 9 key elements
• Conclusions

4. Rationale and context
• Aspiration and momentum….
– SUN movement
– Nutrition for Growth summit
– Lancet series
• …..and ground-level realities
– Coverage of quality nutrition-specific package poor
where most needed
– Enhancing nutrition sensitivity of wider development
policies and programs remains challenging
– Enabling environments: gap between political
attention and system commitment

5. In sum…
There is now a relatively strong consensus on
what needs to be done, but much less is known
about how to operationalize the right mix of
actions in different contexts, how to do so at a
scale that matches the size of the problem, in an
equitable manner -- and how to do so in ways
that link nutrition-specific and nutrition-
sensitive interventions.

6. Scaling up definitions (examples)
• “More quality benefits to more people over a wider geographical area
more quickly, more equitably, and more lastingly” (IIRR 2001)
• “Identifying the most effective ways to channel additional resources in order to
maximize impact on the MDGs” (DFID 2013)
• “To efficiently increase the socioeconomic impact from a small to a large
scale of coverage (World Bank 2003).
• “Scaling up: the ambition or process of expanding the coverage of health
interventions, but can also refer to increasing the financial, human and capital
resources required to expand coverage” (Mangham LJ et al. 2010)
• “Scaling up means expanding, adapting and sustaining successful
policies, programs or projects in different places and over time to reach a
greater number of people.” (Linn JF, Hartmann A 2008)
• “Deliberate efforts to increase the impact of successfully tested pilot,
demonstration or experimental projects to benefit more people and to foster
policy and program development on a lasting basis” (WHO, Expandnet 2011).
• “Scaling up is a process of expanding nutrition interventions with proven
efficacy to more people over a wider geographic area that maintains high levels
of quality, equity, and sustainability through multisectoral involvement.”
(SPRING 2014)

7. Is it about making
something bigger?....
….or about generating
greater impact?

8. …can also be about change…

9. …or evolution…

10. Our working definition
“Scaling up nutrition refers to processes aimed
at maximizing the reach and effectiveness of a
range of nutrition-relevant actions, leading to
sustained impact on nutrition outcomes”

11. Objective of the review
To synthesize what is known about scaling up in
general from nutrition and other disciplines, in
order to distill critical elements to guide actions
that focus on scaling up impact on nutrition.

12. Lancet (2013) framework
(drawing upon Lancet (2008) and ultimately on UNICEF 1990)
12

13. Methods
• Literature search (Google Scholar, PubMed, 2000-2013)
• Keywords: scaling up, going to scale, diffusion, expansion,
mainstreaming, nutrition, health, agriculture, development.
• Expandnet and Brookings bibliographies
• Active consultation with key experts
• Condensed to 42 papers
– Theoretical frameworks (24)
– Program experiences (18)
• Long list of elements and features
• Later condensed/merged to 9 key elements
• In-depth case studies of 4 scaled up programs

14. Some frameworks….

16. Gillespie 2004
VISION/GOAL
Impacts (outcomes, benefits)
CAPACITY ELEMENTS
INSTITUTIONAL ARRANGEMENTS
CDD ACTIVITIES
Sparks
CONTEXT;
- local
- wider

17. WHO 2010

18. Chandy and Linn 2011

19. Results

20. 9 elements are key to effective scale up
1. Vision and goal: where are we going?
2. What is being scaled?
3. Context/enabling environment
4. Drivers and barriers
5. Strategy, process and pathways
6. Capacity to scale up
7. Governance
8. Financing scale up
9. Monitoring, evaluation, learning, accountability

21. 1. Vision:
where are we going?
• Has the vision been clearly and collectively
articulated with a compelling narrative that explains
why it’s important, and how it can be attained?
• “Beginning with the end in mind” (WHO/Expandnet 2011)
• Appropriate indicators of impact and success
• Vision determines metrics for accountability

22. 2. What is being scaled?
• A process, principle, project, technology, innovation,
or methodology?
• Is there evidence of efficacy? Of large-scale
effectiveness?
• What works at small scale (drivers of success) may
not work at large-scale, and/or may change in the
process of scaling.
• Interventions differ in scalability
– relative advantage over existing products/practices
– compatibility with existing values and practices
– simplicity and ease of use
– “trialability”
– visibility of results
– adaptability and “communicability”

23. 3. Under what conditions?
• Macro-economic, social, economic, cultural, political
and historical conditions and trends
• Institutional arrangements
• Positive/enabling, neutral, negative/disabling
• WHO (2013) review: disturbing conclusions
• Community and household contexts
• Implementation context
– Stand-alone projects, integrated programs

24. Simpler intervention Complex intervention
Simpler
context
Vit A supplementation
through campaign.
Distribution of
micronutrient powders to
homes through NGO
platform
Complex (multi-component) behavioral change
communication intervention through community-
based nutrition-focused NGO program platform.
Agricultural diversification intervention through
nutrition-focused NGO program platform
Complex
context
Vit A/iron-folate
pills/calcium supplements
through multi-purpose,
multi-tiered government
health system
Integrated complex behavioral change
communication, micronutrient supplementation and
agricultural extension intervention through women’s
self-help groups and links with government health
systems.
Integrated continuum of care (community to facility
and back to community) for screening, identification,
referral, treatment and follow-up and management,
of severe acute malnutrition through multi-purpose,
multi-tiered government system
Illustration of the intersection of intervention complexity
with implementation context complexity

25. 4. Drivers and barriers
• Internal and external
• Actors/stakeholders
– Leaders, champions, policy entrepreneurs
• Government owndership
• Incentives/disincentives

26. 5. Scaling up strategy
• What will be done, and how will it be done?
• Theory of change
• Processes and pathways (following Uvin 2000)
– Quantitative: intervention expands in size, geographical base, or
budget (also referred to as ‘scaling out’);
– Functional: increases in the types of activities and integration
with other programs;
– Political: increases in political power and engagement;
– Organizational: increases in organizational strength/capacity.
• Simultaneous/sequential
• Purposive/emergent

27. A learning process (Korten 1980)

28. 6. Capacity to scale up
• Defined by level…
– Individual, organizational, systemic
• …..and by purpose
– Strategic and operational capacities are key
– Capacity to make demands
• Poor quality nutrition service delivery often
coincides in time and space with outdated,
impractical and misaligned nutrition training
programmes and academic curricula.

29. Systemic capacity strengthening:
a hierarchy of needs
enable….. require…..
Tools
Skills
Staff and Infrastructure
Structures, Systems and Roles
Brough and Potter (2004)
e
(
2
0
0
1
)
Gill
e
s
p
i
e
(
e
(
2
0
0
1
)

30. 7. Governance
• Structures and systems that underpin processes of
scale up
• Horizontal (cross-sectoral)
• Vertical (national to local) coherence
• “Scaling down” (of central power, resources) often
needed for sustainable scale up.
– e.g. Thailand in 1980s

31. Horizontal and vertical coherence
Verticalcoordination
high
Good cross-sectoral coordination
&
Good cooperation between
centre and local levels
low
low high
Horizontal coordination
31

32. Anticipating and resolving trade-offs
1. Ease of scaling vs need for scaling
Reaching “unreached” essential but difficult
2. Speed vs. sustainability
“Alone, I go faster; together, we go further”.
3. Quality vs. quantity/coverage
– e.g. India (Maharashtra)

33. 8. Financing scale up
• Adequacy
– To reach all those who need, and who can benefit
• Stability
– Building capacity, evidence, experience
• Flexibility
– To permit adaptive, devolved management, local
innovation and learning
• Other challenges
– Cost of enhancing nutrition sensitivity?
– Cost of building and sustaining enabling environments
– Who pays?

34. Resources for nutrition (Gillespie et al 2013)
Countrytype
High-burden
countries
Create budget lines, Increase
commitments,
Find nutrition sensitive
opportunities
Fortification,
Logistics,
Local innovation
Market purchases
Donorcountries
Increase commitments,
Create incentives that
leverage high burden
Risk sharing and pooling,
Innovation start ups
Ethical trading
Public-only Private-public
networks
Private-only
Resources for Nutrition34

35. 9. M&E, learning,
accountability
• Limited evaluations of large-scale programs
– Coverage, quality, equity, sustainability and outcomes
– Impact pathways (demonstrating impact and showing
how it was achieved)
• Even fewer evaluations of scaling up processes
and approaches
• Investment in implementation research is needed
• Strengthening institutional M&E capacity
– E.g. Mexico, Thailand, Bangladesh

37. Conclusions
• Need for greater coherence and consistency with regard to the
“ends and the means” of scaling up – its scope, purpose and its
essential processes.
• 9 elements need to be brought together, enabled or activated
• Go beyond scaling up nutrition-specific interventions and
cultivate leadership and enabling policy environments.
• Walking the talk -- without a scale up in strategic and operational
capacities for planning and action at different levels – whether
designing or implementing nutrition-specific interventions, or
maximizing the nutrition-sensitivity of other sectoral actions – it
will not be possible for the current global momentum to be
translated into sustainable impact on the ground. Short to
medium term project funding cycles of 3-5 years will not be
enough for this – what’s needed is a 10 year investment roadmap.

38. Thank you
Acknowledgements:
Transform Nutrition/DFID (evidence review)
A4NH and USAID/SPRING (conference participation)