Any entrepreneur with a successful program thinks of enlarging it or “taking it to scale.” This is just as true of public health as of private business. Many public health programs are developed at a community level and effectiveness research is conducted to evaluate them. Once research indicates that a program works in a local setting, interest often develops to expand it. In some cases, the expansion succeeds, but at other times, barriers are encountered and the process of taking the program to scale fails.
Research literature on taking a project to scale has been developed, which draws on a range of program experiences, thus leading to the development of various models for the process. This monograph identifies the critical success factors at various stages of program replication and provides insights that may be useful to those seeking to take programs to scale.
Previous research and experience on taking programs to scale has identified five phases that should occur sequentially. At each phase of the process, the implementation team must make a conscious decision about the advisability of moving on to the next stage based on the outcome of the previous stage. The five phases, which are discussed in detail below, are
- initial program implementation, and
- ongoing program operations.
Throughout this phased approach, care must be taken to ensure that replication activities are well thought out and the conditions for successful replication are carefully examined. As a result of this careful examination, a “go-no-go” decision should be made following the exploration phase to avoid proceeding ahead on the basis of “wishful thinking.” Further, this phased approach provides for greater clarity of roles and responsibilities as the process unfolds. Finally, this approach allows for progressive development of relationships that are central to effective partnerships in taking programs to scale. A few examples may help to illustrate this approach.
Taking Public Health Programs to Scale: A Few Examples
The Information Network for Public Health Officials
In 1992, as part of a concerted national strategy to strengthen the nation's public health infrastructure, the Information Network for Public Health Officials (INPHO) initiative was launched.1 The central features of the initiative were to provide public healthcare professionals with access to the benefits of computer systems (in the very early days of the Internet) and to facilitate systems use through enhanced network connectivity, electronic access to information, and data exchange for public health program purposes. Program development mirrored the phases noted above with a flagship effort in the state of Georgia, which was followed by INPHO projects in 12 states across the nation. The Centers for Disease Control and Prevention (CDC) played the role of the central coordinating focus and served as the “purveyor” in the early stages of program implementation. Each state INPHO program shared lessons learned as the network evolved. The key role of training and the development of program metrics early in the process were critical success factors in this pioneering effort, as well as the role of strong program leadership and management skills.2
Centers for Public Health Preparedness
In 2000, as the specter of bioterrorism began to emerge, a growing national concern regarding the preparedness of the public health workforce led to the creation through CDC of the Centers for Public Health Preparedness program at schools of public health across the nation. Initially, four sites were funded at four major schools of public health (Columbia University, the University of Illinois at Chicago, the University of Washington, and the University of North Carolina). As in the INPHO program, CDC served as the central program coordinator providing program guidance and technical assistance. As the program grew to involve 25 schools of public health, CDC continued to convene the network, allowing for sharing of lessons learned.
Public Health Leadership Institutes
In 1992, in response to a clear need for organized leadership development for public healthcare professionals, a national Public Health Leadership Institute was created. A few years later, a network of state/regional public health leadership institutes was created. In this case, development of the network derived from a successful national program, which led to regional replication and program development following the national model. The role of convener was created through a National Public Health Leadership Development Network, which included those who manage the regional programs. The phases of taking the network to scale mirrored those noted above. These programs now serve nearly every state in the nation, and more than 3 000 scholars have participated in network leadership development programs since 1992.
Multistate Learning Collaborative on health agency accreditation and quality improvement
In 2005, the Robert Wood Johnson Foundation established the Multistate Learning Collaborative to promote promising practices in health agencies that were involved in or considering agency accreditation and quality improvement. Initially, 5 states were funded and technical assistance was provided through the National Network of Public Health Institutes. In many respects, network development has followed the “loose” coupling model noted above, with a broad range of program approaches connected through a central coordinating focus. The network has grown to include 16 states, with extensive sharing among peers, making the peer assistance network approach noted a reality.
Phases of Taking Programs to Scale
Phase I: Preexploration
In implementing programs such as these, a “preexploration” phase should occur in which program originators take stock of the critical attributes and success factors of the program. Central to the preexploration phase is the question: “Is the program worth replicating?” In discussing this issue, the word replication will be used even though the process of taking a program to scale is never as simple as “replication.” Typically, programs are adapted to local needs and conditions and often improvements in program operations are identified during this process. “Replication” rarely occurs.
During the preexploration phase, program originators must develop a clear logic model or “theory of change” 3 that underlies the guiding assumptions and practices of the program. The ability to articulate clearly the theory that underlies the program model and also the critical program elements is key to facilitating a discussion on program replication. The theory of change should have as few elements as possible, with a clear explanation of cause-and-effect relationships.
Furthermore, the originators must clearly state the necessary and desired inputs, outputs, and outcomes of the program in ways that lead to concrete metrics that can be used to measure program performance. In addition, a business model must be specified, including a careful assessment of both start-up costs and costs of ongoing program operations. In all of these preexploration analyses, the central question remains: “Is the program worth replicating?” or, in other words, “Does the program work and how do you know that it is working?” In addition to answering this question, program originators should be able to answer another question: “Why is the program working?” In addressing these questions, program originators should be able to articulate “critical success factors” needed in establishing the program (Table 1).
Similarly, program originators should also be able to articulate critical success factors in maintaining a program (Table 2).
Once these preexploration activities are completed successfully, the program originators are in a position to enter into exploratory discussions with other groups having an interest in the replication of the program.
Phase II: Exploration
Next, program originators may enter a phase of “exploration” during which a model of replication is developed and factors are identified that will determine success in a potential partner. Exploration consists of intensive discussion with a prospective partner to determine whether the conditions exist to support program replication in another site. As part of the exploration process, a conscious go-no-go decision should be made with respect to engaging in further dialogue with a potential partner around program replication. Central to the success of the exploration phase is being explicit about “what is being taken to scale.” Program originators must be explicit about what the essential program elements are, which program elements can be modified without jeopardizing the program, the target audience or beneficiary, the business model, and the required staff attributes and skills, including training and recruiting strategies. There are several key questions that should be asked when engaging in an exploratory process with a potential partner (Table 3).
Through a structured dialogue with a potential partner, the program originator can better gauge the level of interest and capability needed to effectively move into a phase in which program installation can be commenced.
In the early stages of the exploration process, development of a business plan should be initiated (Table 4).
Potential funders will need to see much of the information contained in the business plan as they decide whether to provide program support, especially the timeline and specific costs by each stage of implementation. A recent guidebook4 provides public healthcare professionals with step-by-step guidance for developing a business plan and should be used during the exploration stage and subsequently.
Tight versus loose coupling
In addition to these considerations, the originating program leaders should begin to consider the nature of the developing relationship with a new partner. In some cases, a “tight” coupling may be desirable, in which the originator exerts tight control over operations at a new site. For example, fast-food franchises are tightly controlled by a central administrative process, which leads to careful replication of a range of business and production processes from site to site. In contrast, a “loose” coupling may be more appropriate in which new sites operate within an agreed-upon conceptual framework but adapt program operations in light of local needs and circumstances. The “loose versus tight” determination is typically more of an evolutionary process that flows from the evolving relationship between the originating site and new partners as the partnership develops over time.5
As the exploration phase is being completed, the originators should engage in an analytic process to determine whether the partnership should be pursued. A part of this decision-making process should include the potential partner, but ultimately, the originator must make the final decision to proceed. At times, by failing to make this explicit decision, partners may proceed in a context of “wishful thinking” in hopes that, even though some of the initial findings of the exploration phase may not be auspicious, something positive may develop. The research literature and collective experience indicates that a reality-based approach using the structure outlined above is more likely to predict long-term success.
Key determinants of deciding to move ahead into implementation activities relate to the level of buy in/motivation among the local staff, support from the local organizational context, and clear financial support from key stakeholders. Further, there is always the element of timing; the partners should decide: “Is this the right time to move ahead?” Timing issues are particularly important now in view of the continued economic impact of the recession, both on resource availability and on openness to embark on a new program in the face of a range of challenges related to the recession.
Central to the exploratory discussions will be considerations of intellectual property or, in other words, “Who owns what?” These issues are best addressed through the creation of a written memorandum of understanding, which specifies what intellectual property is under consideration and what institutional and individual ownership considerations apply. In public health practice, much information is in the public domain, particularly information developed with funding from a federal government agency, and must remain in the public domain. At times, products developed under other funding arrangements may be considered in a different way.
Phase III: Installation
Once a decision is made to partner with another group for the purpose of replicating a successful program, the process of “installation” begins, in which active collaboration occurs between program originators and those who seek to replicate or, more likely, to customize the existing program to meet the context of a new environment. In this phase, a critical success factor is the involvement of a purveyor whose role consists of both “exporting” program elements and processes and engaging in dialogue to explore the “fit” of the existing program to the new setting.6 The purveyor is typically an individual who was involved in the initial creation and implementation of the program being replicated. As a result he/she understands from personal experience the lessons learned during the initial phases of program development.
Another key component of the installation phase consists of an accurate assessment of the start-up costs and the need for various forms of strategic consultation and technical assistance. Strategic consultation is crucial in the early installation phase and should consist of questioning basic assumptions and confirming levels of commitment from key strategic partners. At this stage, it is often helpful to ask the question: “If we are very successful, what will have happened?”
Technical assistance needs should be anticipated in the installation phase and during the initial implementation phase. Partners should agree on how to measure success and the nature of the ongoing relationship, including roles and responsibilities. Resource sharing arrangements should be clear and a formal memorandum of understanding is useful in setting the terms of engagement during the installation phase.
The three most important activities during the installation phase are planning, training, and development of the evaluation plan and processes.5 The purveyor is central to the execution of each and may play a key role in installation activities (Table 5).
The process of installation may require a considerable investment of time and resources; this is critical to the overall success of the process of taking any program to scale. Initial implementation of a program, the next phase, should not occur without careful and deliberate attention to the exploration and installation phases. The majority of efforts to take programs to scale fail because of the lack of adequate commitment to the exploration and installation activities.3
Phase IV: Initial program implementation
Once installation occurs, the program originators will continue to collaborate with a new partner in a subsequent phase of “initial program implementation” (Table 6). Some of the key elements of activity in the implementation phase will have begun earlier in the installation phase.
In addition to the four key focus activities, purveyors in the initial implementation phase often also are involved in monitoring quality, developing partnership arrangements, convening groups, information sharing, and protecting the “brand” through the initial implementation process.
At this phase, the relationship between the originator and the new site will become more formalized with routine communication protocols and site visits to facilitate early program success. One critical success factors in early program success is the identification of “low-hanging fruit,” which vary from program to program. In the case of training programs, for example, early success is often related to “getting the right people in the room” by ensuring that initial participants in the program are well positioned to take full advantage of program learning opportunities.
At some point in the initial implementation process, the partners should formally reflect on the status of implementation efforts and revisit the go-no-go decision. As in any relationship, it is desirable to have a concrete and conscious decision regarding the success of the effort and the commitment to proceed to ongoing program operations. If the decision is made to proceed, it is always best to stop and celebrate before launching forth into the next phase of activity.
Phase V: Ongoing program operations
Finally, during the phase of “ongoing program operations” at the new site, collaboration will continue between the originating site and the new site as the originating site serves as a central coordinating focus, providing the new site with resources and consultation services. At this stage, the partnership then evolves into an ongoing relationship that is designed to enhance program functioning. As a result, the relationship may take on more of a network quality, in that more reciprocal benefits will develop. As other new sites are identified, the formation of a peer assistance network or a “community of practice” may be useful as a vehicle for sharing lessons learned.
Further, evolution of the role of the central coordinating site will occur and the central site will take on an ongoing responsibility for ensuring quality, facilitating learning, and providing certain central services. The relationship between a central coordinating site and “peripheral sites” will go thorough an evolution as the peripheral sites assume greater degrees of autonomy, as their capacity increases and their experience deepens.
Over time, as a network evolves, the need for regular convening of the network participants along with key stakeholders (especially key funders) will be essential as a core sustainability strategy. Further, such convening will be of value in ensuring that programs evolve as needs and conditions change over time.
A major threat in taking programs to scale: “The paradox of success”
Programs in the nonprofit sector often face a major challenge, which has been described as the paradox of success, in which funders often “declare victory” following the initial implementation phase. As a result, a substantial reduction in program resources often occurs and staff members must turn their attention to the development of new resource streams while continuing to manage the program and maintain program quality. This phase of program development is particularly challenging and must be attended to early in the process of program evolution—if not, the program may collapse despite initial successes. To address this challenge, diversification of funding support from the outset is essential. Further, early development of a business plan that incorporates a long-term financial sustainability plan based on realistic cost and revenue projections is also crucial.
Policy research and a range of program experiences have elucidated a series of phases that programs should follow in taking a proven intervention to scale. The importance of following a staged approach has been demonstrated through a range of community-based intervention efforts, including those that relate specifically to public health programs. Using this staged approach should be useful in considering the process of taking programs to scale and in developing partnerships to do so.