Milat et al.

Implementation Science (2015) 10:113

DOI 10.1186/s13012-015-0301-6
Implementation
Science

SYSTEMATIC REVIEW Open Access

Narrative review of models and success

factors for scaling up public health
interventions
Andrew J. Milat1,2*, Adrian Bauman1 and Sally Redman3

Abstract
Background: To maximise the impact of public health research, research interventions found to be effective in
improving health need to be scaled up and delivered on a population-wide basis. Theoretical frameworks and
approaches are useful for describing and understanding how effective interventions are scaled up from small trials into
broader policy and practice and can be used as a tool to facilitate effective scale-up. The purpose of this literature
review was to synthesise evidence on scaling up public health interventions into population-wide policy and practice,
with a focus on the defining and describing frameworks, processes and methods of scaling up public health initiatives.
Methods: The review involved keyword searches of electronic databases including MEDLINE, CINAHL, PsycINFO, EBM
Reviews and Google Scholar between August and December 2013. Keywords included ‘scaling up’ and ‘scalability’,
while the search terms ‘intervention research’, ‘translational research’, ‘research dissemination’, ‘health promotion’ and
‘public health’ were used to focus the search on public health approaches. Studies included in the review were
published in English from January 1990 to December 2013 and described processes, theories or frameworks associated
with scaling up public health and health promotion interventions.
Results: There is a growing body of literature describing frameworks for scaling health interventions, with the review
identifying eight frameworks, the majority of which have an explicit focus on scaling up health action in low and
middle income country contexts. Key success factors for scaling up included the importance of establishing monitoring
and evaluation systems, costing and economic modelling of intervention approaches, active engagement of a range of
implementers and the target community, tailoring the scaled-up approach to the local context, the use of participatory
approaches, the systematic use of evidence, infrastructure to support implementation, strong leadership and
champions, political will, well defined scale-up strategy and strong advocacy.
Conclusions: Effective scaling up requires the systematic use of evidence, and it is essential that data from
implementation monitoring is linked to decision making throughout the scaling up process. Conceptual frameworks
can assist both policy makers and researchers to determine the type of research that is most useful at different stages
of scaling up processes.

Introduction Both the failure of effective public health initiatives to

The transfer of new knowledge from research into policy influence public health practice and the lag between evi-
and practice continues to be sub-optimal [1]. A major dence generation and implementation represent a consider-
reason for slow progress is what some call the “know-do able impediment to population-wide health improvement,
gap”—the gap between what is known in research and what as it denies or delays community access to effective services
gets implemented [2]. [3–5]. Even where there is evidence of the efficacy or effect-
iveness of public health interventions, there has been much
* Correspondence: [email protected] less attention paid to the mechanisms for delivering them
1
School of Public Health, University of Sydney, Sydney, Australia to scale [6].
2
Centre for Epidemiology and Evidence, New South Wales Ministry of Health,
73 Miller St North Sydney, North Sydney, NSW 2060, Australia
Full list of author information is available at the end of the article

© 2015 Milat et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Milat et al. Implementation Science (2015) 10:113 Page 2 of 11

Scaling up is the process by which health interventions Table 1 Study designs, review search terms and databases used
shown to be efficacious on a small scale and or under con- in the literature review of scaling up public health action
trolled conditions are expanded under real world condi- Study descriptions Review search terms Review databases
tions into broader policy or practice [7]. The concept of Theoretical and Scaling up OR MEDLINE (general
scaling up is different from routine adoption as it involves opinion pieces medicine)
an explicit intent to expand the reach of an intervention Scalability OR CINAHL (nursing and
to new settings or target groups and is accompanied by allied health)
Case studies Intervention
systematic strategy to achieve this objective [8]. research OR
The issue of how best to scale up health interventions Translational EBM reviews—Cochrane
has been receiving recent attention, particularly in the research OR database of systematic
reviews 2005 to
global health literature [7, 9] but there are few studies Descriptive studies Research
December 2013
that offer frameworks and methods for the effective scale dissemination OR
up of public health interventions [10]. Intervention Health promotion
Theoretical frameworks and approaches are useful for studies AND
describing and understanding how effective interven- Frameworks Public health AND PsycINFO (psychology
and related behavioural
tions are scaled up from small trials into broader policy Systematic reviews
and social sciences)
and practice and can be important support tools for pol-
Google Scholar
icy makers and practitioners in their efforts to scale up
public health interventions. Such evidence-to-practice
frameworks are gaining greater prominence in public
health and health care [7]. – Published in English from January 1990 to
The purpose of this literature review was to synthesise December 2013
evidence on scaling up public health interventions into – Described processes, theories or models/frameworks
population-wide policy and practice, with a focus on associated with scaling up public health and health
defining and describing the processes and frameworks promotion interventions
that support the scale up of public health initiatives. – Were theoretical and opinion pieces, case studies,
The review also aimed to identify key success factors descriptive studies or intervention studies
and barriers to effective scale up of public health
interventions. For the purpose of this review, ‘concepts’ were de-
fined as scientific methods that provide information
that informs the scale up of interventions such as
Methods epidemiological forecasting, economic methods etc.
Literature review search strategy ‘Theories’ were defined as ideas that explain scale up
The review included publications with a focus on con- and offer principles upon which scale up can be
cepts, theories and models for scaling up of public based. Finally, ‘frameworks/models’ propose a struc-
health interventions. For the purposes of this review, an ture around which scale-up can be organised. Frame-
intervention was defined as a set of actions with a coher- works/models are used to inform decisions and
ent objective to bring about change or produce identifi- judgments about scaling up and often apply multiple
able outcomes [10]. These actions may include policy, concepts, processes and theories.
regulatory initiatives, single strategy projects or multi- Studies focusing on the scaling up of health services
component programmes. Public health interventions are and public health or health promotion programmes
intended to promote or protect health or prevent ill health were included in the review, while studies with a sole
in communities or populations, and they are distinguished focus on health services were excluded. In this review,
from clinical interventions, which are intended to prevent ‘health services’ referred to the provision of clinical care
or treat illness in individuals [10]. Table 1 details the rele- in hospital and community settings. The reference lists
vant study descriptions, search terms and databases cov- of the full papers were also checked, and relevant pa-
ered in the review. pers were included in the final review. The search
The review was conducted in two phases between process is summarised in Fig. 1.
August and December 2013. In phase 1, abstracts The full papers were also reviewed and thematically
were retrieved and assessed against the review cri- analysed [11] to determine key success factors and bar-
teria. For abstracts that met the review criteria in riers to scale-up. The papers were reviewed and a code
phase 1, full papers were retrieved and were assessed frame developed by the lead author in discussion with
against the review criteria. Studies included in the re- co-authors. The lead author then recorded the fre-
view met the following criteria: quency of mentions of success factors and barriers.
Milat et al. Implementation Science (2015) 10:113 Page 3 of 11

Fig. 1 Literature search process and numbers of papers identified, excluded and included in the review of increasing the scale of public
health interventions

Results examine concepts, theories and models in any great

Findings of the literature review detail (so were excluded), 11 papers provided accounts
Search results of scaling up processes of public health interventions
An initial review of abstracts in electronic databases and 25 papers described concepts, theories and models
against the inclusion criteria yielded 100 abstracts, and relevant to scaling up public health interventions. The
searches of the grey literature further identified four majority of papers excluded from phase 1 of the review
documents. Of the 104 papers and documents reviewed (n = 41) focused on health service interventions,
against the inclusion criteria, 29 papers recommended particularly expanding anti-retroviral treatment for HIV
effective interventions for scaling up, but did not in low income countries.
Milat et al. Implementation Science (2015) 10:113 Page 4 of 11

In phase 2 of the review, a total of 38 full papers and process with Australian policy makers and researchers as
reports were retrieved and reviewed against the inclu- follows: [25, 26, 35] ‘…the ability of a health intervention
sion criteria (n = 38), with 11 papers providing ac- shown to be efficacious on a small scale and or under
counts of scaling up processes of public health controlled conditions to be expanded under real world
interventions. Twenty-five papers and reports de- conditions to reach a greater proportion of the eligible
scribed concepts, theories and models relevant to scal- population, while retaining effectiveness’ [25].
ing up public health interventions, of which 24 were
included in the final review. Frameworks for scaling up public health interventions
Additional file 1: Table S1 summarises characteristics of The review identified eight frameworks [7, 9, 23–28]
papers and reports focusing on concepts, theories and (see Table 2), the majority of which had an explicit focus
models relevant to scaling up public health interventions on scaling up health action in low- and middle-income
including reference details, study type, concepts, theories countries, indicating a gap in scaling up methods in
used or proposed, key concepts, elements of the model or high-income country contexts. Of these, three frame-
framework, context and success factors and important works focused on scaling up specific health interven-
findings. A number of studies were both case studies and tions [23, 27, 28] (i.e. insecticide-treated nets for
proposed theoretical frameworks for scaling up public malaria, promoting breastfeeding and maternal nutri-
health interventions and were described as such in the tion programmes), while five propose generic frame-
‘study type’ column of Additional file 1: Table S1. works that can be applied to efforts to scale up a range
of public health endeavours [7, 9, 24–26]. Generic
Study characteristics frameworks will be examined more closely as they have
The literature on processes, theories or frameworks as- the greatest potential to guide public health action
sociated with scaling up public health and health pro- across many areas.
motion interventions is growing rapidly, with 21 of the The oldest of these generic frameworks, the scaling up
24 (88 %) publications in this review published since management (SUM) framework, was developed by Kohl
2006, highlighting that this is a new field of public and colleagues in 2003, and was updated in 2012 [24, 38].
health enquiry. Research in this field continues to be It proposes three key steps with a series of tasks under
characterised by great variation in definitions, processes each step. The first step involves developing a scaling up
and models. Studies in this review could be grouped plan and creating a vision of what scaling up will look like
under three broad themes: economic and mathematical if successfully implemented. Step 2 involves establishing
models and methods [12–15]; scaling up theories and the preconditions for scaling up, with key tasks including
principles [16–22]; and scaling up frameworks (both building the legitimacy of the intervention and the pro-
generic and issue specific) [7, 9, 23–28]. posed approach, constituency building and realigning and
mobilising resources. In the final step, the scaling up
Defining scaling up and scalability process is implemented based on the identification of
Mangham and Hanson [18] suggest that scaling up is factors that can promote extension and sustainability. Key
used primarily to describe the ambition or process of tasks involve modifying organisational structures, coordin-
expanding the coverage of health interventions, but can ating action and performance monitoring.
also refer to increasing the financial, human and capital The WHO and ExpandNet (2010) [7] model developed
resources required to expand coverage. WHO and by Simmons, Ghiron, Fajans and Newton based on earlier
ExpandNet define scaling up as ‘…deliberate efforts to work by Simmons and Shiffman (2007) [39] offers a slightly
increase the impact of successfully tested health innova- different way of systematically thinking about scaling up
tions so as to benefit more people and to foster policy and was developed in light of the literature and expert
and program development on a lasting basis’ [see p. 2 in opinion. The conceptual model accompanying the frame-
7]. The term ‘scaling up’ has been applied in the litera- work consists of five elements, with the scaling-up strategy
ture in several distinct ways including to describe the as the centrepiece and five strategic choice areas (dissem-
following: the dissemination of a new technique, a ination and advocacy; organisational process; cost and
prototype product, or process innovation [16, 17, 21, 27, resource mobilisation; monitoring and evaluation). The
29], epidemiological and economic forecasting; [13–15, framework is guided by four key principles which are
30, 31] ‘growing’ an organisational or system capacity to systems thinking; a focus on sustainability; the need to
implement to a new level [29, 32–34]; and translating a determine scalability; and respect for gender, equity and
small-scale initiative into a government policy [35–37]. human rights principles.
The papers included in this review offered only one def- The framework proposes nine steps for developing a
inition of the term ‘scalability’, which was developed by the scaling-up strategy that involve the following: i) planning
authors of this manuscript in 2011 using an expert Delphi actions to increase the scalability of the innovation; ii)
Milat et al. Implementation Science (2015) 10:113 Page 5 of 11

Table 2 Synthesis of public health scaling up models and frameworks

Model/framework Key components Focus area Process of Context Bibliographic
development references
Scalability considerations Scalability with a focus on the following: Health promotion: Literature review High- [25]
generic and expert income
➢ Effectiveness Delphi process country
➢ Reach and adoption
➢ Human, technical and organisational Resources
➢ Costs
➢ Intervention delivery
➢ Contextual factors
➢ Appropriate evaluation approaches
Scaling up population health A 4-step process for scaling up interventions: Public health: Literature review High- [26]
interventions: guide, New South generic and expert income
➢ Step 1. Scalability assessment: to assess the
Wales Ministry of Health Delphi process country
suitability of the intervention/s for scaling up
➢ Step 2. Develop a scaling up plan: create a
vision of what scaling up will look like and a
compelling case for action
➢ Step 3. Prepare for scaling up: securing
resources and building a foundation of
legitimacy and support for the scaling up plan
➢ Step 4. Scale up: the main tasks that
should be addressed during scale up
9 steps to scaling up, ExpandNet framework involves 9 steps: Health services Literature review Global [7, 39]
WHO ExpandNet and public and interviews health
➢ Planning actions to increase the health: generic
scalability of the innovation
➢ Increasing the capacity of the user
organisation to implement
➢ Assessing the environment and planning
actions to increase the potential for success
➢ Increasing the capacity of the resource
team to support scaling up
➢ Making strategic choices to support
vertical scaling up (institutionalisation)
➢ Making strategic choices to support
horizontal scaling up (expansion/replication)
➢ Determining the role of diversification
➢ Planning actions to address spontaneous
scaling up
➢ Finalising the scaling-up strategy and
identifying next steps
Scaling up management Includes 3 key steps: Health services Literature and Global [24]
(SUM) framework and public interviews health
➢ Step 1: developing a scaling up plan
health: generic
➢ Step 2: establishing the preconditions
for scaling up
➢ Step 3: implementing the scaling up process based
on the identification of factors that can promote
extension and sustainability
Scale up of exclusive Involves the following steps: Health services Systematic Global [23]
breastfeeding and public health: review health
➢ Assess situation, create a policy
breastfeeding
environment conducive to action
➢ Define roles, relationships and
responsibilities of all partners
➢ Establish agreements
Milat et al. Implementation Science (2015) 10:113 Page 6 of 11

Table 2 Synthesis of public health scaling up models and frameworks (Continued)

➢ Review technical support
➢ Define programme strategy
➢ Mobilise resources
➢ Provide training and technical assistance
➢ Develop and use monitoring
and evaluation systems
➢ Monitor coverage and quality
➢ Measure impact and cost
➢ Provide for testing novel approaches
and continuing innovation
Scaling up global health Describes 6 components of the Health services Literature review Global [9]
interventions: framework scaling up process: and public health and interviews health
for success with experts
➢ Attributes of the specific tool or
service being scaled up
➢ Attributes of the implementers
➢ Chosen delivery strategy
➢ Attributes of the ‘adopting’ community
➢ Socio-political context and research context
Breastfeeding gear model Eight interrelated elements: Health services Literature review, Global [27]
and public health interviews and health
➢ Advocacy focus groups
➢ Political will
➢ Legislation and policies
➢ Funding and resources
➢ Training and delivery
➢ Promotion
➢ Research and evaluation
➢ Coordination and goals monitoring
The framework suggests successful multiple
feedback loops and several potential paths
are required to achieve intended innovation

increasing the capacity of the user organisation to imple- six categories: attributes of the specific tool or service being
ment scaling up; iii) assessing the environment and plan- scaled up; attributes of the implementers; the chosen deliv-
ning actions to increase the potential for scaling-up ery strategy; attributes of the ‘adopting’ community; the
success; iv) increasing the capacity of the resource team to socio-political context; and the research context.
support scaling up; v) making strategic choices to support Each of Yamey’s categories will now be examined in
vertical scaling up (policy, political, regulatory, resourcing greater detail, starting with the attributes of the specific tool
or other health systems changes needed to institutionalise or service being scaled up. Keeping the intervention simple
the innovation); vi) making strategic choices to support is considered a predictor of success [40, 41], and technical
horizontal scaling up (replicating innovations in different experts who have managed large-scale implementation also
geographic sites or extending them to serve larger or argue that getting the implementation policies and proce-
different population groups); vii) determining the role of dures scientifically robust and evidence informed before
diversification; viii) planning actions to address spontan- going to scale is crucial for success [42].
eous scaling up; and ix) finalising the scaling-up strategy Addressing the attributes of the implementers, the
and identifying next steps. framework suggests that strong leadership and governance
Yamey (2011) [9] offers a framework and key success play an important role in successful scale up as is getting
factors for scaling up global health initiatives based on a buy-in from local implementers and other key stake-
literature review and interviews with ‘thought leaders’. holders. The framework also recommends using both
Yamey’s framework divides the scaling up process into state and non-state actors as implementers.
Milat et al. Implementation Science (2015) 10:113 Page 7 of 11

The chosen delivery strategy is also of great import- Step 3 describes how to prepare for scaling up by secur-
ance, with the framework recommending the applica- ing resources and building a foundation of legitimacy and
tion of diffusion of innovation theory by focusing on the support for the scaling up plan process. This step involves
five factors identified by Rogers (1995) [43] as being posi- consultation with stakeholders, legitimising change, build-
tively associated with the faster diffusion of an innovation. ing a broad constituency and realigning and mobilising
The framework also describes cascade and phased ap- resources. Finally, step 4 describes the main tasks that
proaches to scaling up depending on the context within should be addressed during scaling up including modify-
which an intervention is delivered. Cascade approaches ing and strengthening organisations, coordinating action
use a ‘train the trainer’ approach that can result in rapid and governance, monitoring performance, quality and
expansion of interventions. Going to scale in a phased efficiency and ensuring sustainability.
manner begins with a pilot programme, followed by step- Though many of these frameworks propose linear pro-
wise expansion and learning lessons along the way to help cesses for scaling health interventions, it is acknowledged
refine further expansion. Tailoring scale-up to the local by their authors that the reality of ‘real world’ scale-up is
situation and decentralising delivery by adopting an inte- that one or more steps in scale up are often missed. For
grated approach to scale-up is also considered important. example, using the Milat et al. 2014 model as an example,
Thinking about the attributes of the adopting commu- initiatives often go from a scalability assessment (step 1)
nity can be facilitated through the active participation to full implementation (step 4), without establishing im-
of the community in planning, implementing, and mon- portant preconditions for success such as building a broad
itoring interventions and is cited as a crucial factor in constituency and realigning and mobilising resources [8,
successful scale-up. Being cognisant of the socio- 19, 26].
political context is a vital consideration in the frame- A common characteristic of scaling up models identified
work, particularly building political good will and align- in this review is that they link many existing concepts in
ment with national policies. Finally, the framework the literature and interpret them together and in relation to
requires due consideration of the research context. This one another to illuminate factors that inform large-scale
can be done by incorporating research into implementa- implementation of public health interventions. Common
tion using ‘learning and doing’ approaches that involve characteristics of these models include a focus on under-
the systematic application of evidence to guide the standing the attributes of the intervention being scaled up
process and incorporate new learning. (effectiveness, potential reach, acceptability etc.), identifying
Milat and colleagues developed a model of ‘scalability and supporting implementers, the selection of an appropri-
considerations’ using a literature review and expert Delphi ate delivery strategy, understanding and accommodating
process in 2012 [25], which was further developed in 2013 the characteristics of the adopting community, taking into
into the ‘increasing the scale of population health interven- account the broader socio-political context, and the use of
tions guide’ [26] for the NSW Ministry of Health in research, evaluation and monitoring data to inform the
Australia. The framework proposes a four-step process for scale-up process. Importantly, these frameworks enable a
scaling up interventions. It differs from other models clearer discourse and common understanding of key con-
discussed as it is specifically designed for scale-up of pub- cepts and methods associated with the scale-up of public
lic health interventions in high income countries and is health interventions.
unique in that step 1 involves a ‘scalability assessment’ that
determines the suitability of the intervention/s by asses- Success factors and barriers to effectively scaling up public
sing effectiveness, potential reach and adoption, alignment health interventions
with the strategic context and intervention acceptability Key success factors for scaling up health interventions
and feasibility. The outcome of this assessment will deter- gleaned from this review, particularly from case studies and
mine whether the remaining steps in the guide should be papers that interviewed implementation experts in order of
followed. frequency of mention in the literature are the following: es-
Step 2 describes how to develop a scaling up plan tablishing monitoring and evaluation systems [5, 7, 11, 13,
which should create a vision of what scaling up will look 17, 20, 25–27, 29–31, 44]; costing and economic and other
like and a compelling case for action. This step involves modelling of intervention approaches [10, 12, 13, 16–18,
documenting a rationale for scaling up, describing the 20, 23, 24, 28, 32, 44]; active engagement of a range of
intervention, completing a situational and stakeholder implementers and the target community [7, 9, 13, 17, 20,
analysis, determining who could be involved in scale up 25–27, 29, 31, 44]; tailoring the scale-up approach to the
and what their role will be, selecting an approach to local context and use of participatory approaches [5, 7, 13,
scaling up, considering options for evaluation and moni- 17, 26, 29, 41, 44]; systematic use of evidence [7, 9, 13, 17,
toring and estimating resources required for scale up 26, 31, 44]; infrastructure to support implementation such
and writing up the plan. as training, delivery systems, technical resources [13, 17, 20,
Milat et al. Implementation Science (2015) 10:113 Page 8 of 11

27, 31, 32, 44], strong leadership and champions [7, 9, 13, evidence. It was widely noted in papers that effective
17, 25, 44]; political will [7, 9, 17, 25, 32]; well defined scale scale-up requires the systematic use of different types of
up strategy [9, 13, 24, 27, 44]; and strong advocacy [7, 9, 12, evidence. For example, Simmons and Shiffman [39] argue
22, 27] (See Table 3). that successful scale-up ‘…requires the systematic use of
There is merit in more closely examining some of these evidence to guide the process and incorporate new learn-
success factors starting with the importance of the use of ing.’ It was also noted that quality control and performance

Table 3 Synthesis of success factors and barriers to scaling up public health interventions in rank order of mentions
Success factors Bibliographic references
Establishing monitoring and evaluation systems [7, 9, 16, 17, 19–22, 24–27, 29]
Costing and economic modelling of intervention approaches [12, 13, 15, 18, 22, 24–26, 28, 30, 31, 44];
Active engagement of a range of implementers and the [9, 19–27, 29];
target community
Tailoring scale-up approach to local context and use of [7, 9, 20, 24–26, 29, 45];
participatory approaches
Systematic use of evidence [9, 23–27, 29]
Infrastructure to support implementation such as training, [21, 22, 24–28]
delivery systems, technical resources
Strong leadership and champions [9, 19, 23–26]
Political will [9, 19, 23, 25, 28]
Well-defined scale-up strategy [9, 13, 19, 21, 23–26]
Strong advocacy [9, 23, 28, 29]
Flexible responses to human resource constraints [18, 25, 26, 46]
Formative research to ensure appropriate intervention design [23, 25–27]
Equity of intervention delivery and monitoring intended and [17, 25, 26, 28]
unintended consequences across socio-demographic profiles
Effective communication strategy [18, 21, 23, 27]
Effective governance and coordination [9, 26, 29]
Clear role definition and delineation [17, 23, 26]
Keeping the intervention model simple [9, 24, 26]
Financing models [20, 21, 28]
Programmes are visible, publicised and effectively packaged [19, 25]
Developing strategies for integration into existing services [19, 21, 26]
Barriers
Not adapting intervention approaches to the local context [18–20, 24]
Intervention costs and other economic factors [12, 22, 25, 32]
Lack of human resources [13, 18, 19]
Resistance to the introduction of new practices due to [18, 19, 26]
capacity constraints
Insufficient investment in implementation infrastructure [17, 18, 45]
including training, monitoring and evaluation systems
Staff recruitment and staff turnover [18, 19, 46]
Lack of political will [9, 32]
Traditional research funding processes are not flexible [19]
enough to support evaluation of scale up
Leadership changes amongst implementation agencies [19]
Poor engagement with stakeholders and thought leaders [52]
Poor role delineation [32]
Maintaining quality and consistency of health interventions [18]
at scale [18]
Milat et al. Implementation Science (2015) 10:113 Page 9 of 11

monitoring systems should replace stand-alone evaluation health [25, 35], it appears to have a similar intent to that of
as interventions increase further in scale and are dissemi- scaling up. Clarifying the meaning and relationships
nated widely into policy and practice. between new and emerging terminology is an important
Information on programme costs and other economic endeavour as it facilitates precise communication amongst
considerations were considered fundamental to making those working and researching an interdisciplinary field like
effective decisions about the appropriateness and feasibility public health [47].
of population-level programme implementation. Failure to There is a growing body of literature describing frame-
address economic outcomes was often noted as a barrier to works for scaling health interventions, with the review
scale-up and the presence of this data was conversely consid- identifying seven frameworks [7, 9, 23, 24, 26–28], the ma-
ered an important facilitator of effective decision making. jority of which have an explicit focus on scaling up health
Consideration of the context within which interven- action in low- and middle-income country contexts. While
tions are delivered was widely identified as an important the majority of these frameworks were specifically devel-
success factor. Tailoring the scale-up approach to the oped for scaling up in low- and middle-income countries,
settings within which they operate such as community they are generally applicable to scaling up public health
characteristics, financial and human resources and local action in high-income contexts as they have a similar focus
socio-political landscape was thought to be facilitated on improving health status through action directed toward
by the use of participatory approaches that include ac- the health of an entire population, or sub-population, rather
tive engagement of a range of implementers and the than individuals. However, population action in high-
target community. income countries is characterised by fewer resource and
Barriers to successful scale-up of public health interven- capacity constraints than in global health contexts. In
tions identified in the review were often the converse of the addition, policy makers in high-income countries can bring
success factors and ranged from the following: not adapting greater technical and system capacity to bear on public
intervention approaches to the local context [18–20, 24], health problems and as such models for scaling up public
intervention costs and other economic factors [12, 22, 25, health action in these contexts should keep this in mind.
32], lack of human resources [13, 18, 19], resistance to the The review identified a number of key success factors in
introduction of new practices due to capacity constraints efforts to scale up health interventions including strong
[18, 19, 26], insufficient investment in implementation leadership and governance [9, 28, 29, 32, 37], active
infrastructure including training, monitoring and evaluation engagement of a range of implementers and of the target
systems [17, 18, 45], staff recruitment and staff turnover community [9, 19, 27, 29] and tailoring the scale-up
[18, 19, 46] and lack of political will [9, 32]. approach to the local context [7, 9, 45].
There were a number of challenges identified in the Costs and economic modelling of scaling up interven-
literature to moving interventions from a ‘research’ phase tions were widely considered fundamental to strategic
to a widespread adoption or scaling up phase in high- decisions about public health programme implementation
income countries. Norton and Mittman’s [19] examination at various stages of scale up [12, 13, 22, 25, 30]. Costing of
of barriers and enablers to scaling up ten promising health an intervention identifies whether the various arms of a
promotion and disease prevention interventions in the programme are receiving money as was intended in the
USA found that many of the organisations implementing original plan and underpins any subsequent economic
the programmes during initial research phases viewed the evaluation [48]. Despite its value, this information is
programmes as experimental and time-limited, and were generally absent from research reports and in particular
reluctant to have interventions become fully integrated published intervention studies [25, 49]. Given the import-
into the organisation’s routine service delivery after the ance of economic data to informing scaling up processes
study. They also found that a number of research teams [25], the field should be encouraged to collect and publish
were subsequently unable to implement the programme data on intervention costs and where feasible cost effect-
according to original experimental protocol in real world iveness of interventions.
settings using community-based organisations (e.g. senior The notion of keeping the intervention simple as a
centres), and had to adapt the interventions to fit typical success factor merits further consideration in light of the
organisations with limited resources. complexity of many population health interventions.
Complex population health interventions can be multi-
Discussion level and multi-component in nature and by virtue of
While the scale of an intervention may seem an obvious this are not simple. However, the literature suggests that
concept, the findings of this review confirm that the terms though the overall strategy may be complex, individual
scaling up and scalability have been applied in different intervention components that are easy to understand
ways and contexts with little consistency. Though scalabil- and adopt by key stakeholders and target audiences are
ity is a less frequently used term in the context of public more readily scaled up.
Milat et al. Implementation Science (2015) 10:113 Page 10 of 11

Finally, the importance of research, evaluation and moni- Conclusion

toring systems to effective scale-up was widely noted as an Theoretical frameworks and approaches are useful for
important success factor [7, 9, 17, 19, 22, 24, 27, 29]. The describing and understanding how effective interventions
systematic use of evidence and data from implementation are scaled up from small trials into broader policy and
monitoring that is linked to decision making throughout practice. There is a growing body of literature describing
the scaling up process can be of great assistance in scaling frameworks for scaling health interventions, most of
processes. It is important that these evaluative and monitor- which have an explicit focus on scaling up health action in
ing frameworks are built into intervention delivery from low- and middle-income country contexts. Effective scal-
the outset and produce reliable and timely information to ing up processes requires the systematic use of evidence,
inform scaling up decision making [7, 9, 24, 25]. and it is essential that data from implementation monitor-
It is also worth noting that three of the generic scaling ing is linked to decision making throughout the scaling up
up frameworks (scaling up management framework and process. Conceptual frameworks reviewed can assist both
ExpandNet; increasing the scale of population health policy makers and researchers in determining the types of
intervention guide) were identified in the grey literature research that are most useful at various stages of a scaling
and were not published in the peer reviewed literature. up process.
This highlights the importance of publishing future
frameworks in the peer reviewed literature to increase Additional file
their dissemination to the field.
Giving close consideration barriers and enablers to Additional file 1: Table S1. Summary of characteristics of studies
describing concepts, theories and models of scaling up public health action.
scaling up interventions in developed country contexts,
Norton and Mittman’s [19] examination of the scale up
Competing interests
promising health promotion and disease prevention in- The authors declare that they have no competing interests.
terventions in the USA suggests that interventions
should be tested in more typical resource-constrained Authors’ contributions
community-based settings before broader roll out. This AJM developed the concept for the paper, independently conducted the
literature search, conducted the paper extraction, assessed and categorised
view is supported by Glasgow and Emmons [50] and papers, conducted the analyses and led the manuscript production. AB and
Rychetnik and colleagues [51] who argue that more SR were involved in the drafting and editing of the manuscript. All authors
funding and reporting of practical trials that address read and approved the final manuscript.

external validity and contextual issues will significantly Author details

1
enhance translation into practice. School of Public Health, University of Sydney, Sydney, Australia. 2Centre for
A limitation of this review was that it did not examine Epidemiology and Evidence, New South Wales Ministry of Health, 73 Miller St
North Sydney, North Sydney, NSW 2060, Australia. 3Sax Institute, Sydney,
efforts to expand the reach and impact of public health Australia.
policies and programmes, where studies did not use the
terms scaling up and scalability to describe such efforts. This Received: 30 November 2014 Accepted: 30 July 2015

was done to impose some degree of specificity of concepts

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