1. Policy imperatives for systems-oriented
approaches to scaling up:
Case example of taking the SDM to national scale
Susan Igras, Rebecka Lundgren, Marie Mukabatsinda,
Arsène Binanga, Foufa Touré
International FP Conference,
Uganda, Nov 2009

2. Scale Up Research: Where are We?
• Extensive research on attributes of innovation,
patterns of adoption, use of opinion leaders
• Inadequate understanding of processes by which
innovations are implemented and sustained
• Information rarely gathered (considered part of
routine program operations)

3. Scale up Research: Some Concerns
• Tendency to focus on individual rather than
systems level
• Typically ignores interpretive process underlying
adoption
• Pro-innovation bias of researchers (who are
frequently part of scale up process)
• Need in-depth mixed-method studies to provide
picture of process and impact
• Not theory-driven

4. FAM Project
Scaling up the Standard Days Method
• DRC
• Guatemala
• India (Jharkhand)
• Mali
• Rwanda

5. Scaling up ≠ Training + FAM in norms
•Norms & procedures
•Training curricula
•Supervision
•HIS
•Procurement &
distribution
•Budget lines
•Provider training
•Availability of CycleBeads
•Supportive supervision
•IEC: new method as part
of FP mix

6. FAM Project Research
• 5 year prospective, multi-
site, comparative study of
process and outcomes of
scaling up a FP innovation,
the Standard Days Method
• Uses ExpandNet model for
planning, monitoring and
research

7. Why Study FAM Scale up?
• Guide the scale-up process of FAM integration
• Maintain momentum and accountability of multiple
stakeholders/actors
• Assess whether scale up is achieved in terms of
outcome and impact
• Describe the process of scaling up
• Understand better determinants of success and failure
• Contribute to program knowledge base on scaling up

8. Case study research (Yin, 1994)
an empirical inquiry that investigates a
contemporary phenomenon within its
real-life context;
when the boundaries between
phenomenon and context are not clearly
evident; and
in which multiple sources of evidence
are used.

9. Hypothesis
-Applying the systems analysis framework and
scaling-up principles articulated in the
ExpandNet framework
-to scaling up the SDM within existing programs
and services
-will lead to more sustainable, quality SDM
services.

10. Case study on scaling up SDM
• Brings us to an understanding of a complex
issue or object
• Can extend experience or add strength to what
is already known through previous research
• Emphasizes detailed contextual analysis of a
limited number of events or conditions and
their relationships

11. Defining the case study parameters
• Logic model
• Relational model
• Performance indicators

12. Defining Success in Scale Up

13. Strategic Choices for FAM Scale Up
Lead to Selection of Inputs
User Organizations-
Activities
• Training and supervision
• Community awareness
raising (IE&C)
• Multi-systems integration
Resource Organizations-
Activities
• Advocacy
• Building leadership
• Capacity building in
systems analysis
• Transferring skills and
ownership

14. ExpandNet Scale up Principles
Influence Strategic Choices
• Participatory
• Systems approach
• Evidence based
• Quality assurance
• Sustainability goal
• Rights oriented and equitable
(gender, vulnerability, and client)

15. Research Questions: Scale-up Outcomes
Client What is the experience of women and men with
the SDM when scaled-up? (Knowledge, attitudes
and use of the SDM)
Service
offering
Is SDM offered correctly by providers?
How does SDM introduction influence quality,
availability and use of overall family planning
services?
System
integration
To what extent has SDM been integrated into
training, IEC, procurement and distribution, and
HMIS? Is included in norms, protocols and
guidelines?
Resource
mobilization
What is the level of non-USAID resources
dedicated to FAM?

16. Research Questions – Scale-up Process
Resource team To what extent do user organizations
assume the roles, responsibilities and
ownership of the resource team during
the scale-up process?
Advocacy/
Dissemination
What is the role of champions of the
SDM?
Organizational
choices
To what extent has the SDM been
offered outside traditional public sector
service delivery?

17. Data Sources for Scale up
Monitoring, Evaluation, and Case
Study

18. Findings from Baseline Research
and Process Documentation

19. Monitoring Performance Benchmarks - Mali
Selected Indicators (as of 6/09)
No. of resource orgs 11 / 16
SDM included in key policies, norms, protocols 5 / 8 revision needed
SDM in pre-service training Initiated
Commodities in logistics & procurement
systems
In CPT
SDM in IE&C materials Yes , revision needed
SDM in HMIS In process
Proportion of SDPs with FAM in method mix 66 %
FAM in surveys (DHS) Under discussion
Funds leveraged for FAM $75,000 (est’d)
Providers trained 4575 / 5394

20. Hlth/FP Program Mgrs and Policy
Makers in Guatemala (n=20)
Political commitment to
SDM scale up
Commitment is there since SDM already integrated (in
norms, training occurring, in materials)
Political factors in SDM
scale up
Some stakeholders not convinced a natural method can
be modern and effective and that there would be
sufficient demand. FBOs, Church, and community based
NGO networks strong supporters
FAM
knowledge/attitudes
Almost all were knowledgeable about FAM (but not
knowledgeable about efficacy trials and rates)
Ability of MOH to
manage SDM scale up
Was within their mandate. If there is demand, they will
support it.
Integration of SDM into
annual planning /
budgeting processes
Not yet in planning and budgeting processes centrally or
regionally. Felt if SDM ‘proved’ it had high demand, it
would be integrated.

21. Provider Interviews / Facility
Assessments in Rwanda (n=155 and n=109)
FAM integration into
norms, guidelines,
policies
2/3 of providers have seen protocols
Most not familiar with norms and guidelines (newly
introduced in Rw)
Status of FAM
services
60% of providers have offered SDM (42% in last 3 months)
15% have offered LAM (99% in last 3 months)
70% have been offering SDM between 1-5 years
Correctness of SDM
info by provider
Most providers offer SDM competently, and do not find
SDM counseling difficult
Service deliv
environment
Providers only have 4-10 min for counseling on FP – not
enough
Status of FAM 91% of visited facilities offering FP offered SDM.

22. Women Survey Respondents-Mali
29
52
39
71
58
38
43
25 26
8
24
3029
23
36
21 18
32
Interfereavec
lesrelations
sexuelles
N'apas
d'effets
secondaire
Acceptable
pourhommes
Efficace Difficlea
utiliser
Difficilea
comprendre
pour
parternaire
Figure 2. Perception (attitudes) des femmes de la MJF
N= 624 Oui Non Nesait pas

23. Most Significant Change (MSC)
Inductive story-based methodology to
understand and document…
• scale-up processes / outcomes not detected
by quantitative monitoring
• unanticipated processes/effects of FAM
scale up
• meanings of scale-up process and outcomes to
partners, stakeholders, communities
• intangible aspects of FAM scale up (advocacy,
leadership, gender equity, informed choice)

24. Benefits of Scale Up Research
• Measures progress
• Identifies needed adjustments
• Involves high level
(all level) stakeholders
• Provides evidence for advocacy
• Maintains momentum and accountability during a
multi-organization/multi-layered process

25. Scale up Research Challenges
• Adapting research to frequently shifting policy
and resource environments
• Experimental designs difficult to implement
• Involving multiple partners in data collection
• Producing relevant, timely data for stakeholders
with diverse needs
•

26. Methodology: Early Lessons Learned
• Operationalization of scale up (indicator selection)
critical for planning, monitoring and evaluation
• Need to pay attention to interpretation of
meanings of indicators
– Definitions of scaling up, integration,
introduction, availability
• Advantages/disadvantages of comparative design
• Relational database has facilitated management of
diverse info/data

27. Scale up Process:Early Lessons Learned
• Systems approach uses broader lens and uncovers
systemic problems – who is responsible?
• Planning for scale up important to gain commitment,
create accountability, avoid common mistakes
• Data conundrum – need new user data to monitor
service expansion and justify value of investment,
SDM users not yet counted in HMIS
• New skills and attitudes needed for effective scale
up, eg, political and systems analysis, transferring
responsibilities for technical / other support

28. If ultimate goal is sustained, equitable
access to new product/service at scale
• Policy makers, donors, program managers need
better understanding of complexity of scaling up
and resource investments
• Introduction is a systems-shifting process
influenced by factors both inside and outside of
immediate FP program environment
• Planning for and monitoring scale up can create
MOH and partner accountability, avoid crisis
management, and help ensure that what is scaled up
is sustained