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Background: Donors often fund projects that develop innovative practices in low and middle-income countries, hoping recipient governments will adopt and scale them within existing systems and programmes. Such innovations frequently end when project funding ends, limiting longer term potential in countries with weak health systems and pressing health needs. This paper aims to identify critical actions for externally funded project implementers to enable scale-up of maternal and newborn child health innovations originally funded by the Bill & Melinda Gates Foundation (‘the foundation’), or influenced by innovations that were originally funded by the foundation in three low-income settings: Ethiopia, the state of Uttar Pradesh in India and northeast Nigeria. We define scale-up as the adoption of donor-funded innovations beyond their original project settings and time periods. Methods: We conducted 71 in-depth, semi-structured interviews with representatives from government, donors and other development partner agencies, donor-funded implementers including frontline providers, research organisations and professional associations. We explored three case study maternal and newborn innovations. Selection criteria were: a) innovations originally funded by the Bill & Melinda Gates Foundation (‘the foundation’), or influenced by innovations that were originally funded by the foundation; b) innovations for which a decision to scale-up had been made, allowing us to reflect on the factors influencing those decisions; c) innovations with increased geographical reach, benefitting a greater number of people, beyond districts where foundation-funded implementers were active. Our data were analysed based on a common analytic framework to aid cross-country comparisons. Results: Based on study respondents’ accounts, we identified six critical steps that donor-funded implementers had taken to enable the adoption of maternal and newborn health innovations at scale: designing innovations for scale; generating evidence to influence and inform scale-up; harnessing the support of powerful individuals; being prepared for scale-up and responsive to change; ensuring continuity by being part of the transition to scale; and embracing the aid effectiveness principles of country ownership, alignment and harmonisation. Conclusions: Six critical actions identified in this study were associated with adopting and scaling maternal and newborn health innovations. However, scale-up is unpredictable and depends on factors outside implementers’ control.
We adopted a case study approach [31]. Our case studies were Bill & Melinda Gates Foundation-funded maternal and newborn health innovations that had been scaled-up. Selection criteria were: a) they were originally funded by the Bill & Melinda Gates Foundation (‘the foundation’), or influenced by innovations that were originally funded by the foundation; b) the decision had been made to scale up, allowing reflection on the factors influencing those decisions; c) their geographical reach was increased to benefit a greater number of people beyond districts where foundation-funded implementers were active. Based on these criteria we selected three case studies from among all maternal and newborn health innovations funded at the time by the foundation in the study settings. We further distinguished between: a) ‘government-led scale-up’, meaning country and state governments deciding on, adopting, funding and leading on the implementation of maternal and newborn health innovations at scale while benefiting from support and learning from donor-funded pilot innovations; and b) ‘donor-led scale-up’ meaning other donors deciding on, adopting and funding donor-funded innovations at scale. Our three case studies were: An innovation allowing community health workers (Health Extension Workers – HEWs) to administer antibiotics to newborn babies with bacterial infections where referral to health facilities was not possible, in 19 districts, implemented by Save the Children USA with foundation funding. The intended outcome was to expand access to effective newborn sepsis case management. The innovation was scaled as one of nine components of the government-led flagship programme Community Based Newborn Care, in 92 districts over a first phase and implemented by a consortium of international nongovernmental organisations. The Ethiopian Ministry of Health financed the programme with contributions from multiple external donors. An innovation that involved supplying smart phones with an application (app) for community health workers (Accredited Social Health Activists – ASHAs and Auxiliary Nurse Midwives) with features to facilitate health communication, workflow checklists and a patient registration system as part of a wider maternal and newborn health data platform. The outcomes of the innovation were expected to include more effective interactions between ASHAs and communities. The innovation was implemented between 2015 and 2017 by a private provider as part of a public private partnership in five of the 75 districts in Uttar Pradesh, with three years of funding from a state government agency. It was influenced by multiple small-scale (typically in one district) ‘proof of concept’ mobile phone-related innovations in the states of Uttar Pradesh and Bihar, funded by external donors including the foundation. The innovation, implemented as it was in five districts, was considered by the Government of Uttar Pradesh to be an ‘expanded pilot’ for potential scale-up across the state. An innovation to incentivise taxi drivers to transport women to health facilities for childbirth implemented across Gombe State by Society for Family Health, a Nigerian nongovernmental organisation, and Transaid, a UK-based nongovernmental organisation, with foundation funding. The outcomes of the innovation were expected to be improved accessibility to health facilities among pregnant women. The innovation was scaled with some modifications across the neighbouring Adamawa State with three years of funding from the UK-based charity Comic Relief, implemented by Transaid, with support from Society for Family Health. The study focused on identifying the critical actions that implementers had adopted to catalyse scale-up of these three case study maternal and newborn health innovations. Based on the scale-up literature (including [4, 7, 24, 25, 27]) we explored the following themes: A common topic guide was drafted to allow for direct comparison across the three case studies and settings. Researchers from Ethiopia, Nigeria, India and the UK reviewed the guide and made adaptations to reflect different country contexts. It was then used as the basis of semi-structured interviews with stakeholders in the field of maternal and newborn health, who were purposively selected for having detailed knowledge of the scale-up of the case study innovations. We selected semi-structured interviewing as our method of data collection since this approach is appropriate for capturing experiences, perspectives, practices and processes [6]. A total of 72 interviews were conducted across the three settings between March 2014 and December 2015. Our respondents represented different constituencies: national and sub-national government, development partners including donors and UN agencies, civil society and private sector implementers of the case study innovations, stakeholders from professional associations and research organisations, as well as frontline implementers delivering the innovations – namely HEWs, ASHAs and taxi drivers (Table 2). This selection of allowed us to capture a balance of views from the different constituencies. The respondents included: managers and directors, technical advisors, programme officers, and evaluation officers and researchers. The interviews were conducted by researchers with substantial experience of qualitative methods. A deductive and inductive approach was taken; we both examined a priori themes and were attentive to and explored emerging themes in our interviews. Our interviewing was consistent with widely accepted approaches to maintaining validity in qualitative methods, including posing open questions rather than leading questions, posing broader questions before more specific probes, and as discussed below, we used triangulation approaches to cross check our findings [19]. Interviews by type of organisation To preserve confidentiality, interviews took place in private spaces, and all respondents gave informed consent before each interview. We used digital sound recorders for data capture where respondents agreed. The data were analysed based on the framework approach [18]. Interviewers wrote up expanded field notes shortly after each interview, based on sound recordings and comprising detailed notes and direct quotes organised under analytic headings. These represented both a priori and emerging themes, as suggested by [13]. Hence, by simultaneously capturing and analysing data under thematic headings, we could identify emerging interpretations and themes for exploration in subsequent interviews. We then created a common analytic framework enabling us to identify and compare common themes across the three settings, as well as those that were specific to individual case studies and contexts [11]. Based on the analytic framework NS and DW coded the expanded field notes. NS drafted the paper, which was critically reviewed by all authors. We adopted several methods to enhance the validity of our findings [19]. We triangulated our data; stakeholders were interviewed from multiple organisations and we cross-verified their accounts enabling us to form a balanced interpretation of the issues being explored. An investigator triangulation approach was taken where we compared and agreed different researchers’ analyses; hence the findings presented in this paper are the interpretation of multiple researchers. We also conducted member checks by presenting and discussing emerging findings with stakeholders in Addis Ababa, Lucknow, London, Seattle and Vancouver. There was substantial consistency between different stakeholder groups on the issues we explored. Our results reflect the views from the different stakeholder groups we interviewed: we present common views across the full range of respondents rather than a select few.
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