Assessing the ‘scalability’ of health programs: 5 tips to think big

Public health interventions need to be designed with scale in mind, but how do you know when a health program is ready to reach a larger population?

A new paper published in Public Health Research & Practice, a peer-reviewed journal of the Sax Institute, tested the Intervention Scalability Assessment Tool (ISAT) to see how it could guide scalability decisions in public health. We talked to the paper’s author, Karen Lee, about the ins and outs of scalability and her top five tips to policy makers and practitioners for growing a health program.

Sax Institute: Firstly, what is scalability (exactly)?
Karen Lee: Let’s say you have an intervention that has been demonstrated to be effective on a small scale. Scalability is the potential for that intervention to be scaled up to a much larger population, or on a wider scale.

Keep in mind that not all interventions can (or should) be scaled up. If you’re taking something that you’ve done in a controlled setting with 100 participants, scaling that up to even 10,000 participants can be a big challenge.

Q: What are the common problems with scaling up too fast, too soon? And how can the Intervention Scalability Assessment Tool (ISAT) help?
A: A lot of the time people think: it’s worked, let’s do it! But there are more things to think about for successfully scaling up.

For example, if you design an intervention to prevent obesity, from a research perspective especially, you might design a comprehensive intervention that includes an education component, a practical component and even say a coaching and support component. It works really well and achieves the impact you wanted it to in your controlled trial. But can something like that be implemented at the population level? It’s not impossible. But the reality is, it probably can’t, simply because of the level of resources required to operationalise such an intervention on a large scale across a diverse range of settings.

It’s about understanding that not every wonderful idea can be scaled up. And that’s where the Intervention Scalability Assessment Tool (ISAT) can be really useful – it gets people to think that process through before making a decision to scale up.

Q: Which leads us to the next question – what are your top tips for policy makers and practitioners who are thinking of scaling up a health program?

1. Conduct a thorough and considered scalability assessment. Remember, not everything that is effective on a small scale can be scaled up. And this is where the ISAT can assist in making that decision. The ISAT provides guidance on what kinds of information will be important for you to make that assessment.

2. Know your context. The perceived need for scaling up some health interventions can be greater than others. Reflecting on the current situation we’re in right now with COVID-19, you can see there was an urgent need to scale up testing, and obviously resources were deployed straight away. But that’s a unique situation. The reality is that most other health interventions (particularly in the area of prevention) can take months, if not years, to scale up. So it’s important to know your context – is the scale up going to be supported by the powers that be? Will it meet a community, strategic or policy need? Understanding that will really help to assess how conducive the environment will be for your intervention to be scaled up and the likely challenges you might face.

3.Build in implementation planning. A lot of people don’t pay enough attention to considering what implementation means and what it’s going to look like when they take something they’ve designed for 100 people to 10,000 or 100,000 people. Things to consider include: what kind of human, financial or infrastructure resources will you need? How could this change existing practices? How will you account for those variations? These are the kinds of things the ISAT will ask people to consider before deciding to scale something up.

4. Consult and engage as widely as possible. Scaling up requires a lot of stakeholders, and it’s really important to bring them along on the journey. I think if you can do the ISAT assessment with a group of stakeholders, and particularly the people who will delivering the interventions, they can help you identify the potential strengths and weaknesses you will face when scaling up. And that in turn can be used to identify strategies for overcoming any barriers you might face.

5. Think sustainably. Scaling up is a very expensive exercise. Even a successful scale up (meaning it’s been done and implemented and now services 100,000 people) often stops when the funding runs out. One thing that we ask people to consider in the ISAT is to think about how you’re going to sustain your scaled-up intervention from the start. This includes the kind of strategies you can develop to help facilitate a longer-term operation of the intervention that’s not just contingent on funding, because we know sometimes that’s a bit unpredictable.

And while not a tip, I do think it’s important to remember that every scale up experience is a valuable one, whether it’s successful or not. It’s really important that we document unsuccessful attempts, so it helps the next group of people who are trying to scale up.

Karen Lee is a Research Officer and PhD candidate at the Prevention Research Collaboration within the Sydney School of Public Health. The Intervention Scalability Assessment Tool (ISAT) is part of her PhD project, which is funded through a scholarship from The Australian Prevention Partnership Centre. Read her full paper here.

This project is funded by the NHMRC, Australian Government Department of Health, ACT Health, Cancer Council Australia, NSW Ministry of Health, South Australia Department for Health and Wellbeing, Tasmanian Department of Health, and VicHealth.

Public Health Research & Practice is an Australian health journal that is committed to publishing innovative, high-quality papers that inform public health policy and practice. Find out more here.