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National Conference
Scaling Up in India:
Lessons Learnt and Way Forward
April 19, 2010
Venue: Gulmohar Hall, India Habitat Centre
New Delhi
population foundation of india
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Documentation:
Usha Rai, Rimjhim Jain and Swapna Majumdar
Editing:
Mohini Kak
© Population Foundation of India
2010
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Contents
1. Introduction
2. Objectives of the Conference
3. Session Plans
4. Deliberations
4.1 The Inaugural Session
4.2 Session I: Scaling Up through Government Systems
4.3 Session II: Experiences of Scaling Up
4.4 Session III: Role of Monitoring,
Evaluation and Evidence Building in Scaling Up
5. Concluding Session: The Way Forward
6. Conference Summary: Some Key Questions Raised
Annexures
Annexure 1: Conference Agenda
Annexure 2: Media Reports
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
1. Introduction
Over the last decade the concept of
scaling up has become common
currency in the development lexicon.
Governments, donors, international agencies
and NGOs alike emphasize the need to scale up,
be it efforts to fight poverty, public health, HIV/
AIDS, malnutrition or providing quality primary
education. This increased emphasis on scaling
up, in large part, is due to the recognition that
there are many promising, or even proven, pilot
innovations with the potential to impact critical
social development challenges, and yet they are
never effectively scaled up.
Global and Indian experience shows that very
few innovative projects go all the way to effective
implementation at large scale with impact. Most
pilots or innovative projects show diminished
impact as they are scaled up. One of the main
reasons for this rather disappointing outcome is
the implicit assumption that scaling up happens
spontaneously i.e. that good ideas naturally attract
interest of governments, donors and other civil
society organizations and actual implementation
at large scale is taken for granted.
In 2002, the MacArthur Foundation supported
Management Systems International (MSI), an
international development agency, to develop a
methodology for scaling-up small pilot projects,
and to field-test the methodology with MacArthur
grantees. MSI successfully designed a three-
step, 10-task methodology for scaling up. The
framework provided a template for scaling
up and included specific, concrete tools and
modules to achieve each step and the tasks
within it. Population Foundation of India (PFI),
with technical support from MSI adopted this
framework in 2006 and has since been applying
the framework to several pilot projects in the
field of reproductive and child health (RCH) and
young people’s reproductive and sexual health
(YPRSH) in India.
The range of projects and the diversity in
outcomes of the scaling up efforts resulted in
an enriching learning experience. To share these
experiences, a National Conference on Scaling Up
in India: Lessons Learnt and Way Forward was
organized on April 19, 2010, with the support
of the Planning Commission and in collaboration
with MSI and the MacArthur Foundation.
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
2. Objectives of the Conference
• To share experiences from health and other social sectors on scaling up within
government and non government systems
• To develop a vision and strategy for scaling up social sector programmes in India
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
3. Session Plans
The workshop was organized into four main sessions:
The Inaugural Session: This session set the tone of the conference. It highlighted the
concept of scaling up and created among the audience a common understanding of the
Scaling Up Management (SUM) Framework used by PFI and MSI in their scaling up efforts in
India. Lessons learnt in this process were also outlined.
The Inaugural Address was given by Mr. Arun Maira, Member, Planning Commission,
Government of India and the session was chaired by Ms. Poonam Muttreja, Country Director,
MacArthur Foundation. Speakers for this session were Mr. A. R. Nanda, Executive Director,
PFI, Dr. Richard Kohl, Technical Director and Project Director, Scaling Up, MSI and Dr. Rajani
Ved, Senior Associate, MSI.
Session I: Scaling Up through Government Systems: Different perspectives on scaling
up were shared in this session. Deliberations centred on the government’s perspective, an
international perspective and a rights-based perspective on scaling up.
The session was chaired by Mr. Arun Maira, Member, Planning Commission, Government of
India. Speakers included Ms. Sudha Pillai, Secretary, Planning Commission, Mr. Larry Cooley,
President, MSI and Dr. A. K. Shiva Kumar, noted Development Economist.
Session II: Experiences of Scaling Up: The experiences of civil society organizations who
had developed innovative models with evidence of impact on key health outcomes and had
worked on ‘scaling up’ these models with varying degrees of success were shared. The session
highlighted both the processes of scaling up and the key lessons learnt.
The session was chaired by Dr. Syeda Hameed, Member, Planning Commission, Government
of India. Speakers included Dr. Abhay Bang, SEARCH, Ms. Mirai Chatterjee, Vimo-SEWA,
Dr. H. Sudarshan, Karuna Trust and Mr. K.S. Murthy, Bhavishya Alliance.
Session III: Role of Monitoring and Evaluation and Evidence Building in Scaling Up:
Deliberations in this session focused on the relevance, role and contribution of monitoring
and evaluation systems and systematic evidence building in both assessing the feasibility of
whether a model should be scaled up and in ensuring that scaling up was effective.
The session was chaired by Dr. Narendra Jadhav, Member, Planning Commission, Government
of India. Speakers included Dr. Prathap Tharyan, Director, South Asian Cochrane Network and
Centre, Dr. Richard Cash, Harvard School of Public Health and the Public Health Foundation of
India; and Dr. T. Sundararaman, Executive Director, National Health Systems Resource Centre
(NHSRC).
Concluding Session: The day’s deliberations were summed up in this session by Ms. Poonam
Muttreja, Country Director, MacArthur Foundation and Dr. Richard Kohl, Technical Director
and Project Director, Scaling Up, MSI.
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
4. Deliberations
4.1 The Inaugural Session
Giving the welcome address at the inaugural session,
Ms. Poonam Muttreja, Country Director,
MacArthur Foundation said that the Foundation
started its work in the area of scaling up with a grant
to the Washington-based Management Systems
International (MSI) to develop a framework for scaling
Ms. Poonam Muttreja, MacArthur Foundation
up which synthesised the best practices of scaling up
methodologies and their application. The framework
was refined following extensive in-country analysis. In
India, the Foundation’s Population and Reproductive
Health programme identified scaling up as an important
strategy in 2005 and had since increased its focus in
that area.
Speaking on scaling up, Ms. Muttreja said that in
the context of social sector development ‘Scaling up’
referred to the process of adaptation and expansion
of programmes to make quality services more widely
accessible and the programmes themselves more
sustainable.
However, while thinking strategically about scaling
up it was important to recognise certain features of
India’s development. These features included diversity,
governance structures, human resource capacity,
finances and leadership. Many ‘good’ programmes
failed when they became ‘rootless’, as the models were
transplanted from one context to another without
paying attention to differences in socio-cultural
practices, norms of decision making and structures of
governance.
In addition to the Indian context, it was important to
consider lessons from other countries and development
sectors before taking a model to scale. Three broad
factors needed to be considered:
• Evidence of success: Often current evidence
base was not enough by international scientific
standards to allow for mass scale up of a strategy or
technology at a particular time; nor did the results
of small scale work necessarily say enough about
practical obstacles and requirements for scaling up
a technology or approach.
• Cost effectiveness: Costs and cost effectiveness
were often an obstacle in sustainable scaling up and
it was important to evaluate these components.
• Complexities of scaling up: To be successful, scaling
up needed to be carefully and strategically planned.
An assessment of the social, legal and political context
and the potential persons likely to be involved had to
be made. It also meant thinking about training people
for scaling up and the costs involved. Sustainability
of a project and understanding local health systems
were other issues that needed to be kept in mind.
Referring to the Foundation’s India programme, Ms.
Muttreja said that while the Foundation funded pilot
projects that had the potential to be scaled up, it
also recognised the need to fund activities that led to
an intervention operating at scale. In this respect, it
transferred it’s scaling up methodology and tools to
it’s intermediary partner organisation in India – the
Population Foundation of India (PFI). The aim was to
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
build the capacity of local NGOs by incorporating scaling
up into their initial project planning and proposals and
give them the skills to implement scaling up once a
project model proved successful. MSI and PFI had
worked with a number of NGOs on their scaling up
strategy, some of whom like SEARCH, VimoSEWA
and Karuna Trust were making presentations later in
the conference. Ms. Muttreja hoped that the meeting
would inform as well as provide impetus for systematic
attention to scaling up so that there were large scale
changes and improved outcomes.
Speaking on ‘Scaling Up: Objectives and Background’,
Mr. A. R. Nanda, Executive Director, Population
Foundation of India, explained how PFI over the last
four years, with the mentorship of MSI and financial
support of MacArthur Foundation, had developed a
strategy of scaling up adapted to Indian conditions.
Having started working on scaling up of reproductive
and child health (RCH) and adolescent reproductive
and sexual health (ARSH) pilots in India from 2006,
he said PFI had developed into a scaling up resource
organization of some credibility. However, it was still
on the learning path and perfection was yet to be
achieved in a sustainable manner.
Explaining the concept of scaling up, he said it referred
to efforts to bring about more quality benefits to a
larger number of people over a wider geographical
area quickly, equitably and in a sustainable manner.
This required an organization or multiple organizations
Mr. A. R. Nanda, Population Foundation of India
to work together and in tandem with the government
and other key stakeholders.
Box 1: Models or Pilots that PFI has worked
with:
• SEARCH - Home based newborn and child care
model
• Karuna Trust - Public Private Partnership (PPP)
model for management of PHCs
• VimoSEWA – Community Based Micro-insurance
• Dept. of Rural Development and Panchayati Raj,
Govt. of West Bengal - Community Health Care
Management Initiative (CHCMI)
• Federation of Obstetricians and Gynecologists
Society of India (FOGSI) - Training medical
officers of PHCs in Emergency Obstetric Care
(EMOC)
• Institute of Health Management, Pachod (IHMP)
- Safe Adolescent Transition in Health Initiative
• Ekjut - Randomized control trial on saving
maternal and newborn lives through women’s
empowerment
• CINI - Promoting Rights-based Action to Improve
Youth & Adolescent Sexual & Reproductive Health
& HIV & AIDS in India (PRAYASH)
• ARTH - Quality and Safe Delivery Services through
Nurse Midwives
He said that there was often a dilution in quality while
scaling up pilot projects or models due to a number
of reasons. Some of these included, non-scalability of
the pilot, inadequate planning and management for
Scaling Up (SU), lack of vision and motivation for SU
and lack of resources and support for SU.
To prevent this, an intermediary organization like PFI
was important to identify these missing steps and
work with the originating organization to successfully
scale up the pilot project. Some of the steps or
activities required for managing effective scaling up
included goal setting, documentation, evaluation,
advocacy, resource mobilization, capacity and system
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
strengthening and monitoring implementation
at scale.
Listing the pilots and innovations that PFI had worked
with on scaling up (Box 1), Mr. Nanda highlighted the
key lessons learnt by PFI in this process. He said the
most important element of working as a resource
organization was the need to build trust and mutual
respect with the originating/pilot organization. This
was critical to successful scaling up.
Other key lessons were:
• The availability of dedicated financial and human
resource for scaling up often determined the success
and failure of scaling up
• Although cost-effectiveness and cost-efficiency were
vital components of scaling up they were often the
least documented part of the intervention
• The originating organization generally had the
desire to scale-up the entire intervention despite
limitations within the adopting organization. This
made scaling up difficult.
Mr. Nanda stated that to be able to successfully facilitate
scaling up, a resource organization should house or
have access to multiple skills. These include strategic
management, analytical documentation, evidence
building, monitoring, capacity building, institutional
development, political understanding, negotiation
skills and advocacy. He concluded his presentation by
sharing the objectives of the National Conference and
expressing the hope that the deliberations would lead
to the development of a vision and strategy for scaling
up in social sector programming in India.
Dr. Richard Kohl, Technical Director and Project
Director, Scaling Up, MSI, spoke on ‘Scaling Up: A
Strategic Management Framework’. Speaking of MSI’s
involvement in developing the Scaling Up Management
Framework, he stated that six years ago the MacArthur
Foundation had the vision to realize that scaling up was
a major issue and asked MSI to prepare a framework
to implement and manage scaling up processes of
good projects. MSI, in turn, was keen to field test
the management framework it had developed across
several countries – a process that was still on - and
took up the challenge of working with organizations to
scale up their models.
Explaining the framework, Dr. Kohl said that there
were multiple starting points to scaling up. Scaling
up did not necessarily need to be carried out only
after a project had ended or had proven its impact.
The process of scaling up could be initiated from
the beginning of a project or from the middle of the
project with the understanding that corrections would
be made as the scaling up process moved along, or at
the end of the project.
The Scaling Up framework evolved by MSI was a three
step and twelve task process. This included:
Step 1: Preparing the Model and Developing a
Strategy
Task 1: Identifying the Innovation
Task 2: Setting Goals and Choosing a Method
Task 3: Assessing Scalability & Filling in the Gaps
Task 4: Reconciling Model, Vision, Method and
Capability Building
Task 5: Mapping the Political Terrain and Developing
an Advocacy Plan
Task 6: Creating Scaling Up Strategy
Step 2: Creating the Preconditions
Task 7: Advocacy for the Issue, Adoption
Task 8: Advocacy for Funding and Implementation
Task 9: Modifying and Strengthening Organizations
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
Dr. Richard Kohl, Management Systems International
Step 3: Rolling Out the Model
Task 10: Establishing Coordination Mechanisms
Task 11: Monitoring for Quality, Fidelity, & Adaptation
Task 12: Ensuring Political, Financial and Institutional
Sustainability
The most important part of Step 1, Dr. Kohl said, was
identifying the model or innovation that was to be
scaled up or ‘what is being scaled up.’ Though this
sounded simple, he said many organizations in the
field were so caught up in their work that they could
not step back and see what could be done to scale
up. What was thus required was for an intermediary
organization to undertake the following tasks:
• Identify the model’s key components
– Technical (What): Drugs, equipment, training
content, BCC (Behavior Change Communication)
– Process (How): Processes both tacit and
intangible
– Contextual: Organizational aspects
– Values: Empowerment, rights-based, gender,
etc.
In the process of identifying the model’s key
components there was also a need to pay attention
to invisibles such as creating ownership, buy-in and
permission, monitoring, supervision and incentives.
He said, tacit or intangible elements, such as ensuring
that women and local communities were treated
with respect and empowered, and that community
ownership or buy-in was created, were as relevant as
the technical components of the model.
Another task in creating a scaling up strategy was
choosing how and who would scale up. For this,
collaboration was vital. Dr. Kohl said that collaborative
methods were distinguished by the degree to which
the organization that implemented the pilot – the
originating organization– implemented the model at
scale. He stressed that the method adopted or selected
for scaling up should be dependent both on the
capacity of the originating organization to implement
at large scale and the capability of the collaborating
organization to implement the model.
Assessment of scalability was another important task
in Step 1. This required an assessment of whether the
model or pilot was:
• Credible and Observable i.e. there existed objective,
independent evidence that provided a clear link from
intervention to impact
• Relevant: based on an analysis of issues, policy
priorities and beneficiaries
• Relative Advantage: whether it had relative
advantage over existing practices or other competing
alternatives in impact and in cost effectiveness
• Easily Implementable i.e. it was simple, had few
components and had more technical than process
oriented components
• Easily Transferable i.e. there was only a small gap
in the capability and the culture of the adopting
organization as compared to the originating
organization. Compatibility with the existing culture
of potential beneficiaries was also important
• Affordable: the model had to be financially viable
and fit within the available fiscal envelope. The
economies of scale needed to be worked out.
The next task was to reconcile the goals, model,
method and capacity of the organization. Dr. Kohl said
it was often found that the goal and the model did not
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
align. At this point tough questions had to be asked
in order to alter either the goals or the model or the
scaling up method or even the organizations involved.
This required juggling around to:
• Simplify the model
• Lay down more modest goals
• Pursue alternative methods
• Identify organizations with the capability and
capacity to implement at large scale (and ensure
the identification was realistic and feasible).
Moving on to Step 2 which involved creating the
preconditions for scaling up, Dr. Kohl emphasized the
importance of advocacy. He said the first thing that was
required was to ensure that the issue being advocated
was important for the people. In other words, either
there should exist a demand for it or the issue should
be important enough for a demand to be created
through advocacy. Advocacy, he said, was required
both for the issue (that is, for the intervention) and
for funding (for implementation).
Other pre-conditions for scaling up included:
• Capability and capacity building of organizations in
the following areas:
– Governance, accountability and organizational
culture
– Systems, infrastructure, procedures and regulations
– Generic skills, model-specific skills and alignment
of incentives
• Creation of horizontal and vertical coordination
mechanisms
• Monitoring mechanisms to ensure a balance
between fidelity to the model and its adaptation to
local circumstances
Step 3 in the scaling up process, Dr. Kohl said, involved
the actual roll out of the model and efforts to ensure
its sustainability. This required garnering political,
financial and institutional support for the model.
• Political support meant building broad-based
advocacy along with a mechanism for feedback.
Concerted efforts were required to ensure the
pilot being advocated was not associated with
any particular party or person in power but
was institutionalized instead. Knowledge about
competing interests was important in this regard
• Financial support meant going beyond donor
funding for scaling up
• Institutional support meant developing the capability
to reproduce the required skills
With this brief description of the framework, Dr. Kohl
concluded his presentation.
Dr. Rajani Ved, Senior Associate, MSI encapsulated
in her presentation the work done by MSI in the past
four years. She spoke on the ‘Lessons Learnt in using
the Scaling Up Management Framework in India’ and
said the objective of their efforts was to demonstrate
Dr. Rajani Ved, Management Systems International
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
and promote a systematic approach to scaling up;
develop case studies and tools for training in scaling
up; and work in partnership with an intermediary
organization.
Box 2: Specific issues that the NGO pilots
worked with on scaling up addressed:
• Home-based newborn care
• Community-based health insurance
• Management of public sector health facilities
• Training Medical Officers in Emergency Obstetric
Care
• Incentives to frontline providers of immunization
• Delaying the age of the mother for the first
childbirth
• Improving adolescent reproductive and sexual
health through school and community-based
interventions
Mentioning the specific issues and interventions taken
on by MSI and PFI in their scaling up work (Box 2), Dr.
Ved said that one of the key learnings from their effort
was that the level of interest in scaling up was not
backed by institutional investment. She stated that
while both funding and patience were vital ingredients
for scaling up, both were in short supply.
In addition, there was often insufficient, credible
evidence for scaling up which was important not only
for deciding upon the scaling up intervention but also
for developing a scaling up strategy. She pointed
out that scaling up required an understanding of the
social context of a project, developing a sense of
ownership among both the adopting implementing
organization and the beneficiaries, and building
effective collaborations spanning institutions and
regions. All these were challenging requirements
which necessitated patience and focused efforts.
Dr. Ved reiterated the need for patience when taking a
project to scale. She said the organization scaling up
the pilot often expected results in just a year or a year
and a half, whereas it generally took about 7-8 years
for a pilot to become successful at scale. It was also
important for the organization to learn to deal with
competition and political maneuvering for scaling up
among several identical models addressing the same
issue.
Another issue vital for successful scaling up was
ensuring a balance between fidelity to the model and
adaptation to local circumstances. Giving an example
of the ICDS programme, she said that MSI, while
studying the ICDS programme found that States tended
to adhere to the original model with such fidelity that
there was little flexibility for adapting the programme
to their own contexts. She further pointed out that
it was also necessary to carry out an assessment of
whether the proposed scaling up model “fit” with
current policy priorities. For instance, it was more
difficult to get scaling up support for adolescent health
programmes since the priority for the government was
maternal and child health.
Emphasizing the need to ensure congruence of the
scaling up strategy with the capabilities of adopting
organizations, Dr. Ved said, that scaling up plans
should be backed by sufficient financial and human
resources and should also span technical, political,
financial, and organizational issues. For instance,
scaling up plans should be developed keeping in mind
the existing political and social issues in the State.
She pointed out that since a system’s capacity was
not infinite, scaling up might imply tradeoffs, scaling
down or additional systemic resources. However,
while doing so it was important to keep in mind that
scaling up selective components from the pilot model
may not reproduce results. Identifying and retaining
all essential components of the model was therefore
critical. It is also vital to carefully monitor the entire
scaling up of the pilot for improved outcomes.
Dr. Ved pointed out that scaling up had much more
potential and possibilities than what was immediately
obvious. There were several avenues of scaling up other
than through the government. This included people’s
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
collectives, panchayati raj institutions and NGOs. To
overcome human resource shortages, tasks could be
shifted, multiple skills developed, interaction between
technical experts and managers increased and more
attention given to true decentralized planning.
Some Key Lessons of Scaling Up:
• the level of interest in scaling up is not backed by
institutional investment
• there is often insufficient, credible evidence for
scaling up
• the scaling up strategy should be congruent with
the capabilities of adopting organizations
• scaling up might imply simplifying the model –
identifying ‘basic’ or essential components and
‘deluxe’ components that may not be necessary
to incorporate
• scalability should be built into the design of pilots
and include stringent monitoring and evaluation
mechanisms
Looking at the path forward, Dr. Ved said scalability
should be built into the design of pilots. Right from
the start of a project there should be a vision for
scaling up and a clear understanding of the processes
involved. While scaling up attention must also be
paid to gender, equity and quality issues. Financial
resources for scaling up must include monitoring and
learning and there must be an attempt to go beyond
monitoring and evaluation to continuous feedback
and performance improvement. She concluded by
stating that scaling up skills must be inculcated within
resource and training organizations and a culture for
the same imbibed within the social sector.
The presentations were followed by an inaugural
address by Mr. Arun Maira, Member, Planning
Commission. Mr. Maira said he was attending the
meeting in the capacity of a learner and not a mentor.
He said listening to the achievements and challenges
of scaling up, he recollected a global survey that was
carried out some years ago among large MNCs asking
them to recall their greatest challenge. Most of them
said it was developing the ability to reconcile conflicting
interests, that is, reconciling global and local interests
simultaneously. This challenge, said Mr. Maira, seemed
to hold true not just for large corporations but also
for scaling up. Scaling up too could only be successful
when it managed to apply what had so far been locally
appropriate to a larger scale. Thus, the need was to
devise solutions that were effective at both global and
local levels at the same time.
He acknowledged that there was a view that the
Planning Commission sat in an ivory tower while
designing policies and programmes for the country,
which were not implementable. It was therefore
important for the Commission to learn about systems
and processes in order to design a system whose
capability improved over time. For this, it was important
for the Commission to believe that it too could learn
from others and that it alone was not the ‘learned’
one.
He said that in a system that engaged with people,
the process of learning and change to achieve scaling
up must incorporate three phases - how to build
consensus towards an aspiration; preparing the right
conditions before implementation, which included
identifying the processes required for scaling up and
the tools required to facilitate it; and developing a
view of on the adopted scaling up process by picking
up the right signals.
Mr. Maira pointed out that while everyone believed
the government had the capacity to take things to
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
scale, it should be kept in mind that the government
too had its own theories on how to do things, which
were often directly opposed to civil society’s theories
of how to achieve things. He said in government,
designing was done in detail not leaving any scope for
people in the field to design or experiment. Everything
was pre-determined and even the monitoring of the
programme was inbuilt.
Concluding his address, Mr. Maira asserted that there
was a need to change existing basic theories and
learnings and take things forward differently.
4.2 Session I: Scaling up through Government
Systems
Chairperson: Mr. Arun Maira, Member, Planning
Commission, Government of India
Panelists: Ms. Sudha Pillai, Secretary, Planning
Commission, Government of India; Mr. Larry Cooley,
President, MSI; Dr. A. K. Shiva Kumar, Development
Economist
Speaking on ‘Scaling up: Perspectives of the Planning
Commission’, Ms. Sudha Pillai, Secretary,
Planning Commission, Government of India said
that the National Conference focused on a subject on
which discussion was long overdue. She said while
the Eleventh Five-Year Plan articulated the need for
inclusive growth, allocations to the social sectors had
doubled from the Tenth Plan itself. This resulted in
an increase in the number of social sector initiatives
across the country, however, most of them remained
unconnected agglomerations of efforts.
India today, Ms. Pillai said, presented two models of
social sector programmes:
• A national paradigm, which applied to all parts
of the country. This paradigm often did not work
because it required that a single shoe fit all, which
was not always possible.
• ‘Pilot’ programmes initiated by NGOs/donor agencies,
which largely remained small islands of excellence.
Ms. Pillai said that in a country the size of India, most
Ms. Sudha Pillai, Planning Commission
‘pilots’ remained as such. Donor agencies supporting
these pilots had to move on after the project period and
typically the result was that the pilots were not scaled
up and not internalized in the system. It was therefore
important to talk about and share such experiences,
and the Conference provided an opportunity to do so.
She went on to describe her own experiences in
working with the States of Assam and Kerala, where
there was a very short agricultural working period
because of long and heavy monsoons. Programmes
for these regions had to be ‘tailor-made’ and yet be
scalable. That, she said, was the challenge.
While ‘a pilot’ was a very seductive concept because
it galvanized the programme on the ground, it could
not always be scaled up. Given this reality, she said,
it was important for a lot more initiative to go into
making schemes. For example, in developing the
NRHM (National Rural Health Mission), working groups
were constituted to help broaden and scale up the
programme across the country.
Her advice to civil society was to have inbuilt
developmental milestones in pilot programmes to
facilitate scaling up. As far as the government was
concerned, she felt it needed to respond to people’s
growing demands for education, food and healthcare.
These she believed, could not be met by launching
pilots but by embarking on large scale projects that
factored in specific needs of different regions and
incorporated some flexibility.
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Ms. Pillai’s address was followed by Mr. Larry
Cooley’s (President, MSI) presentation on ‘Global
Experience: Seven Practical Lessons on Scaling Up’.
He said that the focus of his work was on mining
innovations and taking them forward. His life, he said,
had been spent in trying to figure out how to make
small things large. He said that getting large systems
to make changes was incredibly difficult, which was
why conceiving of an up-scaling plan and then actually
implementing it was a tough task. The lessons he had
learnt in this process were:
Lesson 1: Most projects labeled as “pilot projects”
did not include scalability assessment or strategies to
improve prospects for scaling up. He said that effective
pilots were those that included strategies such as early
engagement of key decision makers, careful testing
and documentation, and anticipated the realities of
large scale implementation.
Mr. Cooley pointed out that the word ‘pilot’ these days
simply meant ‘small’. However, in reality, ‘pilot’ meant
a model or intervention that was suitably designed
right from the start to go to scale. The purpose of a
pilot was not to successfully meet the needs of a small
population but to make it successful among a larger
population. Unless a pilot could move to a larger scale
it was in essence a failure, however successful it was
at the small level. A small project, therefore, could not
automatically be considered a ‘pilot’.
Lesson 2: The more one could simplify a model –
without losing the basis for its effectiveness – the
Mr. Larry Cooley, Management Systems International
more feasible it was to scale it up. Mr. Cooley pointed
out that there was a strong reluctance on the part of
most organizations to simplify, repackage or relinquish
control over their models for the purposes of scaling
up. The intermediary organization sometimes had to
force this through. Infact, many a times there was a
complete refusal to scale up because of this essential
‘simplify’ process.
Lesson 3: Transferring responsibility to and from
government was very dependent on the details
of governance in particular localities, States and
countries. Transfer of the pilots to the government,
he said, was more difficult when there was a level of
distrust between NGOs and governments. In federal
systems of government like India, relations between
the Centre and the States also affected scaling up and
had to be taken into account.
Lesson 4: The tasks involved in going to scale were
distinct from those involved in operating a successful
pilot and from operating at scale. In many cases, there
was a conspicuous lack of intermediary organizations
with the skills, mandate and motivation to help
organizations scale-up successfully, and a shortage
of donors willing to fund the scaling up process.
Mr. Cooley said that when they started working in
India they were particularly struck with the fact that
there were so few organizations present to help as
intermediaries in scaling up. The reason for this could
be that the job of being in the middle and performing
brokerage or an intermediary function lacked funding
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
as well as glamour. Nevertheless, he emphasized,
that this was an area that needed a lot of attention
and that focus should be placed on developing such
intermediary organizations.
Lesson 5: Going to scale was particularly difficult when
models:
• lacked credible documentation of impact
• did not include a technological innovation
• were value-laden or process-intensive
• were replacements or substitutes for government
services rather than innovations in service delivery
• were not easily grafted onto existing services; or
• did not have a dedicated funding source or some
other means of generating revenue.
Mr. Cooley also emphasized the importance of a
‘dedicated funding source’ for scaling up. He added
that any scaling up strategy should further recognize
and incorporate the fact that government systems
were generally resistant to change.
Lesson 6: For sustainable change to occur, it was
essential to understand and replicate the incentives
from the model or make sure that an alternative
incentive system reinforced needed actions. To
enable this, Mr. Cooley said that there was often a
need to change the rules, regulations and procedures
which required detailed knowledge of the adopting
organization.
Lesson 7: It was essential to monitor and report on
both the scaling up process and implementation at
scale. Mr. Cooley said that this was not just a technical
function but a political one too, as monitoring and
reporting helped keep people’s attention on the
process of scaling up. The monitoring and reporting
process thus could and should be used as part of an
ongoing strategy to maintain political and popular
support, as well as funding.
Mr. Cooley concluded his presentation by observing
that although scaling up was a small enterprise in
India at present, it was important to nurture it.
Speaking on ‘Issues of Gender and Rights in Scaling
Up’ Dr. A. K. Shiva Kumar, noted Development
Economist, did a quick recap. He stated that the
proceedings had so far highlighted the fact that
there was growing interest in scaling up, which was a
process that was critical in helping to meet the human
development aspirations of people. At the same time,
when not done properly, it sometimes led to corruption
and mismanagement of the system. It was therefore
important to know how to handle scaling up in the
right manner.
While scaling up could be done by the voluntary sector
(through Self Help Groups and other community based
organizations), by the markets, especially where
livelihood issues were involved (for example, where
handloom initiatives had to be made commercially
viable), the main role in social sector scaling up, he
said, had to be played by the government. However,
scaling up through government systems involved
a number of constraints which included – too much
centralized planning, inflexible financing, low quality
standards and poor human resources.
This, Dr. Shiva Kumar said, led to the fundamental
question – how does one achieve scaling up through
a system that was so imperfect? He suggested that
instead of complaining that the government was
corrupt and inefficient, there was a need to recognize
that the process had to be made to work even in this
imperfect system.
Dr. A. K. Shiva Kumar, Development Economist
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He said interventions in the social sector were
necessarily multi-sectoral. Thus, for instance, while
taking into consideration the implementation of the
Right to Food Act, apart from ensuring access to food
one had to look at a host of other related factors like
health, education, nutrition and women’s
status, among others. The same held true
for a health intervention, where there was
a challenge of scaling up in a very complex
environment with multiple organizations/actors and
multiple issues.
One also needed to consider, he said, how to ensure
scaling up was accompanied by social values.
In every aspect of the programme’s design and
implementation, values of respect and dignity must
be built in. How much social value had been created
through the programme was equally important. In
the case of health programmes, Dr. Shiva Kumar said,
it was often found that after the initial very rapid
success in scaling up, there was a roadblock. About
30 per cent of the targeted group remained out of the
programme’s coverage. This almost always comprised
the poorest, most marginalized and inaccessible
communities, which occurred because the strategies
for ‘universal coverage’ never actually considered this
left-out group. Often, what was required to reach tribal
populations was very different from what was required
for other social groups. Thus, he recommended that
the bottle/can be turned upside-down, with the most
marginalized groups being the primary focal point of
any scaling up effort.
Dr. Shiva Kumar also highlighted the need to re-look
at the criteria for evaluating the success or failure of
a pilot project or its scaled up version. For instance
instead of considering just cost effectiveness, it was
more important to ensure that every child had access
to food and education however expensive it was. He
emphasized that ‘successful’ scaling up in the social
sector could not be evaluated by the usual yardsticks,
and pointed out that there were deep rooted biases of
gender and other issues that had to be understood in
their social contexts before passing judgments on the
efficacy of a programme. While scanning programmes
for scaling up, he said, priority should be given to
those programs that gave access to basic services to
the most vulnerable, discriminated and disadvantaged
communities. Documentation too should focus on
these aspects.
He concluded by stating that successful scaled up
programmes were only those that put people at the
centre of decision making. In social sector interventions,
it was important that the personal touch was not
lost, as it did sometimes when scaling up happened
mechanically from 100 districts to about 500.
Snippets from participant discussions.
‘There was a need for social development programmes
to focus on the poorest and most underserved
communities like those living in the naxalite-torn areas
of Jharkhand, rather than trying to cover the entire
country.’
Dr. Prasanta Tripathy, Ekjut
‘There was a big price to be paid for constantly
innovating and changing well established successful
interventions. In a country like India it was very difficult
to start with pilots, which were often designed only
when funds were limited and to satisfy a particular
Ministry. Instead of having pilots, big projects
should be designed in such a way that feedback
was constantly received from the community and
there was inbuilt flexibility to change and adapt the
programme in the areas required.’
Ms. Sudha Pillai, Secretary,
Planning Commission, Govt. of India
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
Snippets from participant discussions.
‘In a country as large as India, it could not be
assumed that there could be a universal solution
for development. Pushing scaling up when most
communities in India were deeply disaggregated
was questionable, since scaling up could lead to
larger mistakes. Instead, there was a need to discuss
accountability.’
Dr. Abhijit Das, Centre for Health
and Social Justice (CHSJ)
‘While the Government had the capacity to scale
up innovative ideas, intermediary organisations
were needed to support and encourage project
implementation.’
Dr. N. K. Sethi, Senior Adviser (Health),
Planning Commission, Govt. of India
Concluding Remarks from the Chair: The
Chairperson of the session, Mr. Maira, wrapped
up the session by stating that while intermediary
organisations served a useful role they did not produce
the ‘learning’ that was to be scaled up. They helped
only to disseminate it. He said that there were some
minimal fundamental rules of scaling up that needed
to be learnt, not the details of scaling up which could
be different in each case. He ended by emphasising
the ability to collaborate as being fundamental to
scaling up.
4.3 Session II: Experiences of Scaling Up
Chairperson: Dr. Syeda Hameed, Member, Planning
Commission, Government of India
Panelist: Dr. Abhay Bang, SEARCH; Dr. H.
Sudarshan, Karuna Trust; Ms. Mirai Chatterjee,
Vimo-SEWA; Mr. K. S. Murthy, Bhavishya Alliance
Speaking about the session Dr. Syeda Hameed,
Member, Planning Commission, Govt of India
said each of the presenters in the session were icons
in their field. Their path breaking work – each in a
different area of social development – among the
most marginalised communities was being replicated
with great success. She stated that their experiences
provided useful pointers about scaling up in India.
Dr. Abhay Bang the founder director of SEARCH,
Gadchiroli, Maharashtra, spoke on ‘Scaling up of
Home-Based Newborn Care’, an intervention pioneered
and developed by his organisation. Outlining the
extent of neo-natal and infant mortality in India,
he said that IMR in India was 58 while the national
goal was to reduce it to below 30. He pointed out
that approximately 70 per cent of IMR was the result
of neonatal mortality. There were about one million
neonatal deaths in India annually. It was thus vital to
know how to provide newborn care to prevent these
deaths.
The Home Based Newborn and Child Care (HBNCC)
model of SEARCH, said Dr. Bang, was originally piloted
in Gadchiroli district of Maharashtra. The goal of the
model was to reduce neonatal mortality by developing
a low cost home-based model of primary neonatal care
by tapping the human potential in villages. The model
was based on the assumption that newborn deaths
could be reduced by preventing or treating morbidities,
such as infections, asphyxia or hypothermia. The key
components of the model included:
• Community Engagement through sensitisation and
engagement of key stakeholders in the village
• Training of Community Health Workers (CHWs)
• Intensive supportive supervision
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
The key concepts behind HBNCC were:
• Focus on newborns
• From hospital to home
• From neonatologist to Community Health Worker
(CHW)
• From mere health education to life saving skills
• From helplessness to empowerment
in India and to other underdeveloped countries. The
method chosen to scale up was replication through
the government system and the strategy adopted
for the same was advocacy and capacity building of
government functionaries. Training programmes and
modules for building the capacity of stakeholders and
field functionaries to implement the model were also
developed.
Dr. Bang said the implementation of the HBNCC model
resulted in a significant decline in IMR in Gadchiroli
over a period of time (1988-2003). A costing of the
model further showed that the cost per death averted
was Rs.6772 annually, which was well worth the
outcome.
Scaling up efforts, he said, were initiated by first field
testing the model in multiple settings through the
ANKUR Project. The project tested the replicability of
the model in seven sites in Maharashtra through seven
NGO partners with the support of Saving Newborn
Dr. Abhay Bang, SEARCH
Lives Initiative. The trial implemented HBNCC in
91 villages and six urban slums in different parts of
Maharashtra during the period 2001-05 and resulted
in the reduction of neonatal mortality rate by 51- 67
per cent and reduction in infant mortality by half.
After the success of the trial, Dr. Bang said, a vision and
a plan for scaling up the model was developed which
focused on scaling up the model to five lakh villages
Advocacy efforts for Scaling Up, Dr. Bang said, began
with a National Convention in 2006 in New Delhi where
the results from the Gadchiroli trial, ANKUR Project and
Indian Council of Medical Research (ICMR) mid-term
review were shared. The convention was attended by
a wide range of stakeholders including the Planning
Commission, Ministry of Health and Family Welfare
(MoHFW), State Department of Health and Family
Welfare (Madhya Pradesh and Rajasthan), ICMR,
donors and NGO partners. Following the Convention a
field visit to Gadchiroli was organised for the Planning
Commission, which resulted in the acceptance of the
model by the government and its inclusion in the XIth
Five Year Plan.
Dr. Bang stated that with the launch of the NRHM
and the introduction of the ASHA around the same
time, the environment for implementing HBNCC
had become more conducive. Furthermore, with the
setting up of the ASHA Advisory Group under NRHM,
the process of institutionalising HBNCC became more
possible and with their recommendation the HBNCC
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
training strategy and content was incorporated within
the ASHA training plan. Direct efforts to engage the
State governments were also made.
What made these efforts possible and successful, Dr.
Bang said, was the fact that there was a need for it;
there was strong supporting scientific evidence for the
model; and there existed a demonstration site where
people could come and see how the model was being
implemented and learn and be motivated by it.
Non-recurring Annual
costs (2002- recurring
03 prices)
costs
(Rs.)
(Rs.)
Cost per Village
6,974
5,301
Cost per
40
273
mother–
newborn served
Cost per death
6,772
averted
Cost per DALY
305
saved
Dr. Bang acknowledged the relevance of partnership
building in their advocacy efforts, mentioning the
support extended by PFI, NHSRC and a forum of
NGO partners (National Partnership for HBNCC)
in taking forward the model in India. Highlighting
the key challenges faced in scaling up the HBNCC
model, he stated that the main opposition came from
viewpoints that focused on promoting institutional
deliveries and IMNCI. However, this opposition was
unwarranted as the HBNCC model in essence was
not in conflict with these viewpoints. Infact, it was
complementary. He said, to overcome this opposition
efforts were made to clarify this point and advocate
for a combined package for 0-5 year olds where
IMNCI addressed issues of pneumonia, diarrhoea, and
malaria and HBNCC focused on neonatal mortality.
Similarly, a complementarity existed between the
Janani Suraksha Yojna (JSY) scheme which promoted
institutional deliveries and the HBNCC model. These
efforts at countering doubts in the mind of key policy
makers and other stakeholders, Dr. Bang said, saw the
HBNC (Home based newborn care) model evolve to a
HBMNCC (Home based maternal and newborn child
care) model.
Outlining the efforts made by SEARCH to ensure
‘quality’ implementation of the model at scale, Dr. Bang
said, over the years, SEARCH had developed a variety of
training material as well as developed a cascade model
of training which covered four levels of implementers
– managers, trainers, supervisors and ASHAs.
An evaluation of the training showed that it was
effective in transferring both skill and knowledge to
the trainees.
Today, Dr. Bang said, SEARCH was scaling up the model
with the support of the Ministry of Health, NHSRC and
the ASHA Mentoring group and the result was:
• Incorporation of the model in the XIth Five Year
Plan
• Implementation of the model in 7 districts
of Karnataka with the support of the State
government
• Implementation in 20 Districts of Andhra Pradesh
in collaboration with the Society for Elimination of
Rural Poverty’s (SERP’s) SHG Federation. SERP is
an autonomous society of the Department of Rural
Development, Andhra Pradesh
• Introduction of HBNCC in the ASHA Training Module
6 & 7 and in the Training of National Trainers from
16 States
The model, he said, had also got scaled up in South
Asia and Africa. In South Asia the model was being
replicated in Bangladesh through BRAC’s Manoshi
Antenatal
Delivery
Post-natal
Facility
Home
JSY
HBNC
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
project and through the Sylhet trial; in Pakistan
through the Hala trial; and in Nepal through the MINI
project focusing on successful sepsis management.
In Africa the model was being replicated in partnership
with UNICEF. Advocacy on the same was being carried
out in seven countries of Africa. Managers and trainers
from 11 countries had been trained on the model,
pilots had been initiated in four countries, a UNICEF
training manual had been developed based on the
SEARCH manual and policy change had been effected
in Ethiopia.
Dr. Bang concluded by highlighting the most recent
global policy change – a joint statement by WHO,
UNICEF, USAID and Save the Children in 2009 which
endorsed home visits of neonates and management
of sick neonates at home by trained workers if referral
was not possible. He stated that it took about 20
years since the trial had started and the HBNC study
undertaken to make this change happen.
Dr. H. Sudarshan, Karuna Trust spoke on the
‘Public-Private-Partnership (PPP) model of Primary
Health Care (PHC) Management’. Giving a brief
background of the organization, he said, Karuna
Trust was founded in 1986 in response to the high
prevalence of leprosy in Yelandu taluka, Chamrajnagar
district, Karnataka. At the encouragement of the state
government officials who were impressed with their
work, they subsequently expanded into other fields of
public health. In 1996, the State government handed
over the Gumballi PHC in Chamrajnagar district to
Karuna Trust to manage. Since then, he said, the
Trust had scaled up to five States and 48 PHCs. These
included 26 PHCs in Karnataka, 9 PHCs in Arunachal
Pradesh, 5 PHCs in Orissa, 4 PHCs in Meghalaya and
2 PHCs in Andhra Pradesh, covering a total population
of over seven lakh people.
He said, by 2011, Karuna Trust hoped to expand to
another five States including Manipur, Bihar, Jharkhand,
Jammu and Kashmir and Chhattisgarh in partnership
with the MacArthur Foundation, increasing the number
of PHCs under its management to a total of 100.
Dr. Sudarshan said the main public health challenge
in India was the neglect of primary health care along
with poor health care infrastructure. Even though the
country was committed to comprehensive primary
health care, being a signatory to the Alma Ata
Declaration, a majority of PHCs remained largely non-
functional. This was primarily because of absentee
doctors, lack of health workers, non availability of
essential drugs and overall poor management.
Dr. H. Sudarshan, Karuna Trust
Explaining the three Ps in PPP, he said the first P referred
to ‘Public’ or to the Government; the second P referred
to ‘Private’ which included both the for-profit private
sector and also the not for-profit private sector such as
NGOs and voluntary organisations; and the third P i.e.
‘Partnership’ meant a partnership in all components
of the programme, be it policy formulation, planning,
implementation, monitoring, evaluation, training or
research. PPP did not mean being ‘contractors’ for the
implementation of government programmes.
He stressed on the need for introducing more PPPs
in the health sector, specifically in areas where PHCs
were poorly managed because of lack of political
commitment, inadequate allocation of financial
resources, lack of accountability and absence of
community participation.
The Karuna Trust PPP Model, Dr. Sudarshan said, was
community based, people oriented, need based and
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land, building, equipment, vehicle and records to
Karuna Trust
• Monthly/quarterly advance or financial
reimbursement as per the MoU
• Submission of audited financial statements of the
PHC to the State government
• Sharing of monitoring reports at the district level
• Annual review of process and outcome indicators
culturally acceptable, using appropriate technology
with minimum cost to the community. Elaborating
on the process of PPP adopted by Karuna Trust, he
said, the process began with efforts at advocacy with
State Governments to introduce the PPP concept
in their States. Once the idea was accepted by the
State Government, the government would float an
expression of interest inviting proposals from the
private sector. At this stage Karuna Trust would submit
an application for the same and if accepted would follow
a standard procedure of implementing their model.
The process followed by Karuna Trust in taking over
and managing the PHCs included:
• Identification of poorly performing PHCs in remote/
tribal areas
• Dialogue with the community and with elected
members of Panchayati Raj Institutions (PRIs)
• Application to the Zila Parishad and State govt. to
hand over the management of the PHC by sharing
a draft Memorandum of Understanding (MoU)
• Obtaining consent and finalizing the MoU
• Recruitment and induction training for staff of the PHC
• Withdrawal of government staff from the handed-
over PHC. Although government staff were given an
option to continue at the PHC, most staff opted to
get transferred out
• Formal takeover of the PHC from the District Health
Officer (DHO) and handover of infrastructure,
• Sustained in-house capacity building of staff
The main characteristics of the Karuna Trust
Model of primary health care:
100 per cent headquarter stay of all staff in the
PHC
24x7 PHCs, with just two nurses
Essential drugs available throughout the year
People friendly PHCs that are also gender
sensitive
All buildings and equipments in working
condition
Good referral services
Emergency medical services
Community participation
Integrating mental health, eye care, traditional
medicine, telemedicine and health insurance
Dr. Sudarshan said these procedures helped maintain
a certain quality of management at the PHC. To
ensure continued community ownership, Karuna Trust
also introduced community monitoring mechanisms
as well as several innovations in health care at the
PHC to address peoples’ needs. These included
telemedicine, community health insurance, integration
with traditional medicine, community mental health
programme and vision centres among many others.
All these efforts, Dr. Sudarshan asserted, had resulted
in dramatic differences both in PHC management and
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
in health outcomes. Before Karuna Trust took over,
PHCs were dirty, dilapidated and without electricity.
They had inadequate equipments, infrastructure
and medicines and did not provide regular health
services as the staff did not stay at the PHC. After
Karuna Trust took over, the PHCs were clean and tidy,
renovated, had electricity, adequate infrastructure
and equipments, and medicines and health services
were available round the clock as all the staff stayed
at the PHC.
Infant Mortality Rate (IMR) of Gumballi PHC (1996 - 2008)
80
70
60
50
40
30
20
10
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Cost efficiency was the hallmark of the
model, with the costing of Primary Health
Care being Rs.50 per capita per annum said
Dr. Sudarshan. To make the model replicable for the
government, he said, efforts had been made to ensure
that they worked within the limitations of the financial
and human resources provided by the government.
Dr. Sudarshan said the need for scaling up in
partnership with PFI and MSI emerged because the
Karuna Trust Model of PHC management started
gaining recognition at various levels. At the same time,
the concept of PPP was also becoming popular and
there were demands from other State governments to
start similar initiatives. For example, inspired by the
success of the PPP Model in Karnataka, the Health
Secretary of Arunachal Pradesh asked Karuna Trust
to implement the same model in the north eastern
State. Till then, Karuna Trust had been expanding as
and when the demand arose, with no systematic plan
for scaling up.
Working with PFI and MSI, Karuna Trust developed a
clear scaling up action plan. Dr Sudarshan said this
involved deciding the appropriate method of scaling
up. The choices included (i) scaling up by directly
implementing the programme (ii) scaling up by
entering into partnership with a local NGO and the State
government for implementing the model or (iii) scaling
up by playing the role of facilitator in the partnership
between the local NGO and the State government.
The method eventually adopted by Karuna Trust for
scaling up was a combination of (i) and (ii).
In addition to selecting the method of scaling up, Dr.
Sudarshan said, a number of preparatory activities
were also undertaken. These included:
• Organizational development and capacity building
• Development of a fresh organogram with detailed
job responsibilities
• Development of manuals for HR, Finance,
Operations, Training
• Creation of new posts such as Manager (Scaling
Up), HR Manager, Area Coordinators
• Advocacy for Scaling up:
– sharing the KT Model in NRHM meetings
– sharing with State governments – Orissa,
Meghalaya, Jammu & Kashmir, Andhra Pradesh
and Madhya Pradesh
– advocating at a personal level in different State
and National fora and as a member of the Task
Force on PPP under NRHM
Highlighting the challenges in scaling up, Dr.
Sudarshan said the model faced resistance from a
number of quarters such as private nursing homes,
especially those in the vicinity of PHCs, who felt
threatened about losing their business. In addition,
corruption at district health offices often impacted
timely sanctioning of grants which affected PHC
functioning and the motivation of human resources.
Karuna Trust also had to contend with poor collection
of drugs and vested interests which influenced the
Zila Panchayats against the partnership. Shortage of
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
qualified doctors and ANMs, staff turnover, lack of
budgets for administration, monitoring, supervision
and capacity building, resource constraints with regard
to innovations and difficulties in mobilizing funds to
make up for gaps in government budgets were some
of the other challenges faced. Selection of the right
NGO partner when expanding to new States was
also one of the biggest initial challenges faced while
scaling up.
Dr. Sudarshan concluded by asserting that despite
all obstacles, Karuna Trust had not only been able
to provide good quality health care services but had
also started expanding to PPPs in District Health
Management and the Management of FRUs.
Speaking on ‘Scaling Up Community-Based Micro
Insurance: The VimoSEWA Experience’ Ms. Mirai
Chatterjee, VimoSEWA, presented another
example of successful scaling up. Giving a brief
background of the organization, she said, SEWA was
a trade union of poor, self-employed women workers,
registered in 1972 with its head office in Ahmedabad,
Gujarat. SEWA was more than just a trade union.
It had initiated several programmes to empower
women. These included instituting a bank, establishing
childcare cooperatives, a training academy, other
cooperatives, a health programme and VimoSEWA
(Vimo, is ‘insurance’ in Gujarati).
Ms. Chatterjee said VimoSEWA was started to provide
social security to women workers in the unorganised
sector by offering them insurance. Although it was
started in 1992 as part of SEWA Bank, it was only
in the year 2000 that it became a separate unit. The
main role of VimoSEWA was to act as a facilitator
between women and insurance companies, offering
them a basket of life insurance and non life insurance
products. It provided insurance cover for life, accidents,
health and assets to a group that had higher risks and
lower incomes than the ‘normal’ insurance market.
VimoSEWA she said generated its revenues from the
service charge, investments and technical assistance
given.
The service, Ms. Chatterjee said was started after
their experience in SEWA Bank where they saw the
crippling effects of high health expenditure on poor
families. Not only did it often lead to indebtedness,
it also resulted in women not seeking healthcare for
themselves until they experienced an emergency. More
importantly, poor women were simply not insured as
they were considered a bad risk.
VimoSEWA Factfile:
• The National Insurance VimoSEWA Cooperative
Ltd. is registered with the Department of
Cooperatives, Ministry of Agriculture
• It is run by an elected board of 14 members, all
of whom are women workers
• VimoSEWA’s shareholders include women
workers and their organizations from five States
- Bihar, Delhi, Gujarat, Madhya Pradesh and
Rajasthan
• Current premium collected: Rs.1.25 crore
• Current membership: 1,20,000
Women are policy-holders, 52% of the
membership
19% membership is family coverage
• Total Claims pay-out since 1992: Rs.14 crore to
55,000 persons
Ms. Mirai Chatterjee, VimoSEWA
VimoSEWA was therefore started to make certain
that women workers in the informal sector and their
families were insured and received sustainable health
insurance services.
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The strength of the women, Ms. Chatterjee said, lay
in their numbers and mitigated the risks involved.
The women were poor but when 50,000 of them
became members of VimoSEWA, the insurance sector
sat up and took notice. In January, 2001, following
the devastating Gujarat earthquake, the number of
insured members increased dramatically to 92,000.
While membership continued to grow steadily, a need
was felt to scale up systematically to improve the
viability of the service and minimize risk.
The opportunity to scale up, she said was both
possible and feasible because there were very few
micro insurance players and VimoSEWA was able to
meet the demand gap. In addition, there was limited
risk in scaling up since no major capital investments
were required as VimoSEWA was a facilitator not an
insurer.
Ms. Chatterjee said VimoSEWA started the process of
scaling up by first setting a goal, i.e. ensuring outreach
of insurance in a viable manner to women workers
across their life cycle. Following goal setting they
developed a business plan that outlined growth targets,
geographic spread, partners and strategies. While
partners included the Directorate of Labour Welfare –
which developed the Rashtriya Swasthya Bima Yojana
(RSBY), the Gates Foundation (Avahaan), other
NGOS – mainly Micro-Finance Institutions and SEWA
Bharat, strategies focused on developing appropriate
distribution channels for increasing outreach and
premium collection so as to reduce cost.
Speaking on the major lessons learnt in this process,
Ms. Chatterjee said that with low income people,
especially women, the ticket size of the premium was
low and therefore generating revenues for sustainability
was a challenge. However, with appropriate products
and distribution channels and by scaling up, medium
to long-term sustainability was possible. This required
flexibility in the development of products and services
to suit the needs of the community. While some parts
of scaling up like education and marketing needed
to be decentralized, others parts, such as overall
data management and claims-processing needed to
remain centralized. There was also a need for constant
and continued insurance education to build an
understanding among the community on insurance.
Although a slow process, Ms. Chatterjee said, insurance
education was essential as it led to more people realizing
the relevance of insurance and thereby accessing it. It,
thus, eventually resulted in scaling up insurance by
increasing outreach and ultimately ensuring a viable
micro-insurance organization.
She further outlined some key lessons, as listed
below:
• Scaling up required strong management skills, a
strong team and strong horizontal and vertical
coordination. For this, developing a sense of
ownership through team-building and team-
management was essential
• Capacity building was critical to scaling up and
required both structured training sessions as well as
learning by doing, through an ongoing process of
hand-holding
• Involvement of an experienced team, with a mix of
local staff, professionals, new and experienced, was
a must while scaling up
• Beyond a certain size and complexity of operations,
a separate structure or organization was required.
For example, when VimoSEWA’s membership came
close to two lakh insured members, it became
imperative to hive it off the mother organization,
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SEWA. One of the major reasons for this was that
to grow and scale up appropriately, decisions had to
be made by those who best understood the work—
i.e. the women workers involved in insurance. Thus,
a separate governance structure was required
• Robust data collection and maintenance systems
for tracking trends, growth and underwriting were
key for monitoring and providing timely, supportive
feedback
• Strong and effective monitoring was also required
for facilitating cross learning among teams
• Financial systems and financial monitoring were a
must with regular audits. Every rupee had to be
carefully tracked and utilized with the utmost care
• While scaling up, it was important to maintain the
values and culture of an organization. Even “small
things” counted
Ms. Chatterjee concluded by stating that while scaling
up through the government was advantageous in
terms of outreach, it also had its disadvantages.
Government efforts did not always pay attention to
critical aspects of the NGO model. Thus, civil society
involvement in all stages of scaling up was essential.
Making the final presentation of the session, Mr. K. S.
Murthy, Bhavishya Alliance, spoke on ‘Improving
Child Nutrition in India through Multi Sectoral
Partnership’. Giving an overview of the programme,
Mr. Murthy said that Bhavishya Alliance was created
in 2005, with the support of the Global Partnership
for Child Nutrition, which brought together Unilever,
UNICEF and Synergos Institute as a tri-sectoral alliance.
The goal of the Alliance was to contribute towards
the reduction of child malnutrition. Programmatic
direction for the Alliance was provided by a Governing
Council consisting of members from the government,
NGOs, eminent individuals and corporates (Hindustan
Unilever, TATA Indicom, ICICI, and HDFC).
Mr. Murthy said Bhavishya Alliance started its work
by bringing together more than 30 stakeholders
from government, business and community based
Mr. K. S. Murthy, Bhavishya Alliance
organisations to develop and initiate broad, inclusive,
cross-sectoral pilots aimed at:
• Bridging gaps in service delivery by improving
systems and practices
• Enhancing capacity of stakeholders to meet the
objectives and achieve desired outputs
• Triggering positive responsiveness/behaviours of
communities
He said the value of Bhavishya Alliance’s work was
in bringing together multi-sectoral partners and
showcasing sustainable models or pilots that were
scalable. Mr. Murthy emphasised the fact that
Bhavishya Alliance designed its pilots to work within
government programmes, systems and structures.
The Alliance involved the government from the very
beginning (even before the conceptualization of ideas
for interventions) and continued execution through
government infrastructure. This ensured a very strong
foundation for sustainable replication of the model.
In addition, he said the multi-sectoral nature of the
Alliance facilitated the coming together of diverse
views, ideologies, expertise and methods for a
single cause, i.e. creating solutions to address child
malnutrition.
Pointing out the overall learnings from multi-sectoral
partnerships, Mr. Murthy said that the success of
these partnerships depended on how effectively the
State government initiated corporate and civil society
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engagement; how effectively corporates and NGOs
engaged with each other and with the government
and how the strength of each partner was leveraged.
The effectiveness of the partnerships, he said, was
determined by:
• The vision of the top management who had the
ability to take decisions
• The choice of partners – those sharing the same
values, with similar reputations and cultures
• A long term commitment by partners
• The development of a clear cut strategic framework,
with areas of work, roles, responsibilities,
implementation strategies, interventions and
required resources clearly demarcated
• Varied but complementary involvement of partners
– for example, advisory, funding, monitoring and
evaluation, consulting etc.
• The adoption of a flexible approach by partners
in the interest of learning together. This helped in
continued motivation of partners, pushing their in-
volvement beyond what was agreed
Mr. Murthy stated that achieving good results within
the existing systems and structures without major
external investments was possible through a credible
neutral host organization that liaisoned and neutralised
differences. However, challenges existed in building,
maintaining and strengthening such partnerships. It
was not only a complex and time consuming process
but also required a lot of patience. He said some of
the challenges were:
• Matching the give and take/bring and borrow of
partners
• Convincing the corporates that they were dealing
with an initiative that was likely to deliver value and
success and that their corporate interests converged
with the objectives of the alliance
• Convincing the Government of the value added by
such a partnership
• Gaining the confidence of NGOs who were very
cautious about engaging with corporates and
The Different Pilots designed and
implemented by Bhavishya Alliance
Pilots designed based on the life cycle approach
and focused on systems improvement:
• Improving supply chain of medicines at Primary
Health Centres
• Improving counselling services at Primary Health
Care facilities
• Initiating Anganwadi-cum-Day Care Centres at
construction sites
Pilots focused on enhancing capacity:
• Diversification of food and improvement of food,
hygiene and nutrition in the Supplementary
Nutrition Programme of ICDS
• Health and nutrition awareness programme for
tribal women
• Community empowerment and behaviour change
Pilots focused on Behaviour Change Communication
on Infant Feeding:
• Integrating Behaviour Change Communication on
personal hygiene in government programmes to
reduce infant morbidity
• Empowerment of adolescent girls
suspicious of their potentially conflicting business
agendas
• Ensuring a connection between activities
implemented as part of the alliance and each
organisations or institutions own core activities
• Generating an understanding among partners
on the impact of collaborative work to their own
organisation or institution
• Developing effective measurements of the
success of the partnership and convincing
others to support it
• Providing a clear articulation of what was expected
from each partner and how each partner could be
benefited
• Defining responsible governance structures and
systems for continued involvement of partners
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• Getting the approval and ownership of every partner
(especially the government) for integrating activities
into the mainstream public systems
Snippets from participant discussions.
‘Involving and mobilising women’s groups in health
care by making them active actors instead of passive
recipients in the process would help scale up models
more effectively.’
Dr. Prasanta Tripathy, Ekjut
‘Community mobilisation, health education and
behaviour change communication can bring down
MMR and IMR to an extent, however, beyond a
certain point, case management (i.e. management
of asphyxia etc.) is required to reduce it further.
Thus, both women’s empowerment and home based
new born care are important.’
Dr. Abhay Bang in response to a question
‘Innovators don’t often have the capacity to scale up.
Therefore, partnerships are important to scale up. If
scaling up is to be done through the government
then government organisations like the NHSRC
become relevant partners. On the other hand, when
strong community mobilisation has to be undertaken
then grassroot organisations like SHGs etc. become
the right kind of partners.’
Dr. Abhay Bang in response to a question
‘Facilitating organisations like PFI, MSI and the
MacArthur Foundation help in organisational capacity
development which makes it easier for small NGOs
to scale up.’
Dr. Sudarshan in response to a question
Mr. Murthy concluded his presentation by asserting
that each of the pilots undertaken by the Bhavishya
Alliance could be replicated or scaled up with minimal
policy changes. The Alliance’s efforts had proven
that the government system at the grassroot level
accepted the solutions derived out of these multi-
sectoral initiatives and that they helped achieve larger
social change to some extent, especially in reducing
malnutrition amongst children.
Concluding Remarks from the Chair: The
Chairperson of the session Dr. Syeda Hameed, Member,
Planning Commission, had to leave early for another
meeting and therefore handed over the chair to Prof.
N. K. Sethi, Senior Advisor (Health), Planning
Commission. Summing up the deliberations Prof.
Sethi said it was clear that a partnership with the
government was important in the process of scaling up.
He said if the change agent became a part of the system,
it was easier to scale up. However, while doing so it
was important for the change agent to ensure that the
ownership of the idea remained with the government.
The role of the change agent should primarily be
that of a facilitator where it shared ideas like the
SUM framework and other good practices like those
presented in the session.
4.4 Session III: Role of Monitoring and Evaluation
and Evidence Building in Scaling Up
Chairperson: Dr. Narendra Jadhav, Member, Plan-
ning Commission, Government of India
Panelists: Dr. Prathap Tharyan, Director, South Asia
Cochrane Network and Centre; Dr. Richard Cash,
Harvard School of Public Health; Dr. T. Sundarara-
man, Executive Director, National Health Systems
Resource Centre (NHSRC)
Dr. Prathap Tharyan, Director, South Asian
Cochrane Network and Centre, began his
presentation ‘Cochrane Reviews: Evidence Building for
Scaling Up’ with the hope that he would be able to
address some of the following questions:
• What was the role of formal studies, operations
research and statistical evidence in designing
programmes for scale or deciding to scale up pilot
programmes?
• Was there an objective standard of impact or
of significance that could be applied across the
board?
• To what extent were randomized controlled trials or
quasi-experimental designs appropriate or necessary
in generating evidence for scaling up?
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• What determined the type of designs that were
appropriate?
He said, scaling up efforts should follow the mantra
“don’t just do it, do it right”, however, there was always
a gap between evidence, research and practice which
made this difficult. Getting the evidence straight for
scaling up was just one part of the problem. The other
more important part was getting the evidence used. An
additional problem, he said was determining the quality
of evidence. There existed different levels of evidence, all
of which were not equally convincing. It was important
to assess both existing evidence and also explore what
needed to be done to generate (better) evidence of
efficiency and scalability in pilot programmes.
Dr. Tharyan asserted that in his perception
‘systematic reviews’ were the best way of assessing
evidence. Systematic review was the application
of scientific strategies that limited bias to the
systematic assembly, critical appraisal, and synthesis
of all relevant studies on a specific topic. Many
(not all) systematic reviews used meta-analysis to
synthesize data. Meta analysis was the statistical
technique used to combine the results of several
independent studies that were similar in their methods,
populations studied, interventions and outcomes.
He said the Cochrane Collaboration (www.cochrane.
org) was one of the best places to find good quality
systematic reviews. It was the largest organization in
the world devoted to producing, disseminating and
Dr. Prathap Tharyan, South Asian Cochrane Network and Centre
maintaining systematic reviews (SRs) of the effects of
interventions. He claimed that Cochrane Systematic
Reviews emphasized methodological rigour, were more
up to date, used less biased methods and interpretation
and were also free from conflicting sources of funding.
They were used by WHO and other policy making
bodies world-wide to inform guidelines and help in
changing health practices.
Sharing other good sources of systematic reviews,
Dr. Tharyan recommended the PPD/CCNC
d a t a b a s e ( h t t p : / / w w w . r e s e a r c h t o p o l i c y. c a /
search/reviews.aspx) and SUPPORT summaries
(www.support-collaboration.org). While the PPD/
CCNC database focused exclusively on health systems
arrangements, SUPPORT summaries provided concise
summaries of systematic reviews of the effects of
health systems interventions (as well as maternal and
child health interventions) for low and middle-income
countries.
Dr. Tharyan stated that evidence from observational
studies should not be used for evaluating the effects
of interventions. Explaining why, he gave the example
of the practice of giving hormone replacement therapy
to post-menopausal women. For over a decade post-
menopausal women were encouraged to use hormone
replacement therapy, believing that this would reduce
cardiovascular risks. The data for this information came
from observational studies which showed inconsistent
results and were of very low quality. Systematic trials
conducted later considerably revised this practice and
indicated that hormone replacement therapy should
not be used for the routine management of chronic
diseases.
Reiterating the point that evidence did not automatically
transform into guidelines or practice, Dr. Tharyan
suggested the GRADE approach to facilitate the
translation of evidence into policy recommendations.
GRADE Approach
GR - Grading of Recommendations
A - Assessment
D - Development; and
E - Evaluation
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He said the GRADE approach was a sequential process
of preparing evidence profiles (summaries) and
developing evidence-based recommendations. It used
a multidisciplinary panel with broad representation
(including clinicians, methodologists, generalists,
patient representatives and experienced guideline
developers) and involved proper group processes for
reaching balanced consensus on recommendations.
The processes included:
• Deciding on the overall quality of evidence across
outcomes
• Including judgments about the underlying values
and preferences of management options and
outcomes
• Deciding on the balance of desirable and undesirable
effects
• Deciding on the balance of net benefits and cost
• Grading the strength of a recommendation
• Formulating a recommendation
• Implementing and evaluating the recommended
actions
In addition to systematic reviews for evaluating
the evidence and determining potential tradeoffs in
terms of efficiency, effectiveness and scalability, Dr.
Tharyan said scaling up also required conversion of
this evidence into policy change.
Outlining the essentials for a good policy, he said
the policy making process needed to be structured,
transparent and inclusive. It needed to:
• be informed by the best available evidence to clarify
the problem, frame potential options and anticipate
potential implementation issues
• be rooted in the realities of the people it was meant
for
In other words, Dr. Tharyan said a good health policy
document required that it take into consideration the
differences in disease prevalence and burden, the
different systems of health delivery, the different
guidelines followed by different associations and
organizations, equity issues (socioeconomic, gender,
age, tribal, urban, rural) and the different values and
preferences of diverse stakeholders. It also needed
to look at governance issues of implementation and
regulation.
He said while working on policy advocacy there was
a need to acknowledge and factor the dynamism
of policy making which often had short timelines,
required prioritization of policy options (which were
subject to change) and required reconciliation of
differing viewpoints among policy makers who did not
necessarily understand the language of science. At
the same time there was a need to acknowledge that
health policy making was a global problem with some
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common solutions. While evidence base needed to be
contextualized locally, it was important to recognize
that research evidence (global and/or local) could
often be lacking, incomplete, imperfect, and even
contradictory.
Dr. Tharyan concluded by stating that to win the
trust of stakeholders, a health policy needed to be
based on (and be seen to be based on) an accepted
and transparent process that considered all available
evidence, evaluated strengths and limitations, involved
stakeholders in all steps of the process and monitored
how options were implemented. It also needed to
evaluate impacts, and make adjustments on better
evidence.
Dr. Richard Cash, Visiting Professor and Advisor,
Public Health Foundation of India and Senior
Lecturer, Harvard School of Public Health,
spoke on ‘From Demonstration to Dissemination:
BRAC’s Experience in Scaling Up Health Programs
(Oral Rehydration Therapy and Tuberculosis)’.
Starting with a brief background on BRAC, he
said, BRAC was a social development organization
founded in 1972 in post-war Bangladesh. It had
grown over the years to become the world’s largest
NGO workforce with over 100,000 people. BRAC’s
mission was to work with poor people to bring about
positive change in the quality of their life through
a holistic approach. Their focus was primarily on
empowering women and they implemented a range
of programmes in economic and social development,
health, education, human rights and legal services.
BRAC worked in 70,000 villages in Bangladesh with
expenditures of over $ 540 million, 80 per cent of
which were generated by BRAC’s own activities.
Today, it had a presence in 12 countries.
Sharing details of BRAC’s Oral Therapy Extension
Programme (OTEP), Dr. Cash said through the
programme 12 million mothers in Bangladesh, over
a 10-year period (1980-1990), had been taught how
to prepare Oral Rehydration Solution (ORS) in their
homes. The objective of the programme was to tackle
the high diarrhea deaths taking place in Bangladesh
at the time. The programme was centred on female
OTEP workers whose salary was incentive-based. He
said the knowledge given to the community at the
time still existed in the population. This was evident
from the fact that Bangladesh today had the world’s
highest user rate of ORS.
He then gave another example of a programme that
had been successfully scaled up by BRAC, that is
‘the DOTS Programme for Tuberculosis (TB): Case
Finding and Treatment’. He said the programme
began in 1984 in a sub-district that had a population
of 220,000 with the help of 200 health volunteers
called Shastho Shebikas (SSs). The SSs would identify
cases in the community, refer them for testing and
provide community-based care. The SSs were given
incentives for case finding and ensuring complete
treatment. The programme also provided incentives
for patients. They were asked to sign a bond before
treatment to ensure compliance in drug taking. Dr.
Cash revealed that the cost per case comprised $
64 from BRAC and $ 96 from the Ministry of Health.
He said by 2006, the National Tuberculosis Control
Programme (NTP) - BRAC had expanded DOTS to
cover a population of 83 million. The programme
today covered a population of over 100 million, with
78 per cent case detection and 94 per cent treatment
success.
Dr. Richard Cash, Harvard School of Public Health
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Highlighting the factors that contributed to the success
of the programme, Dr. Cash said the programme
showed:
• Involvement of community workers or Shastho
Shebikas with an incentive system for case finding
and completed treatment was an effective strategy
for an active surveillance programme
• Incentives and involvement of patients through a
bond prior to treatment could ensure compliance in
drug taking
• Treatment at the door-step, provision of free drugs
and reliable delivery ensured both coverage and
acceptance of treatment by the community
• Incorporation of learnings from pilot projects with
independent research and evaluation was beneficial
in strengthening the programme
• Treatment programmes were most effective if
integrated into an overall development strategy
In addition to providing technical lessons on how best
to design and implement a community based health
programme, Dr. Cash said, the programmes also
provided key insights into the essentials of scaling
up health programmes. Outlining some key insights,
he said:
• Institutional vision and a commitment to scaling up
from the beginning or design stage was essential
• It was important to understand that scaling up was
a multidimensional and not a linear process
• It was imperative for pilot programmes to have
research and evaluation components built in from
the beginning
• When designing programmes for scaling up efforts
should be made to keep interventions as simple as
possible
• It was essential to train workers prior to scaling up
The management while scaling up should be appropriate
and down-to-earth with a strong supervision
component. This may require the involvement of new
groups and different skills.
Dr. Cash concluded by stating that evaluation,
adaptation and advocacy were crucial for scaling up.
He also asserted that there was a need to consider
longer, more realistic time frames for scaling up.
Speaking on ‘Evidence Building for Scaling Up:
From Projects to Missions and Movements’ Dr. T.
Sundararaman, Executive Director, National
Health Systems Resource Centre (NHSRC),
shared the experience of scaling up Community
Health Worker (CHW) programmes. He said CHW
programmes were important as they impacted Infant
Mortality Rate (IMR) through prompt ‘life saving’ visits
for diarrhoea, Acute Respiratory Infection (ARI) and
fever. Through the provision of home based newborn
care they also ensured a closure of service gaps,
especially immunization, ante natal care, referrals for
sick children and neonates, counseling on child nutrition
and key health care messages and practices.
Dr. Sundararaman said that while a key criterion for
scaling up was the success of the model in impacting
outcomes, it was not the only criteria that determined
whether a programme was successfully scaled up.
He gave the example of the community health
worker programme in Jamkhed, Maharashtra, which
although a great success (resulting in a dramatic
decline in IMR) failed to scale up. On the other hand,
the Mitanin (community health activist) programme
of Chhattisgarh, was being scaled up with some
success.
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One of the key lessons about scaling up, he said, was
that size mattered. While small scale programmes
with NGO leadership tended to flourish, large scale
programmes implemented by the government
often floundered. He said, this reality needed to be
examined and the following questions answered -
Was dilution and loss of content inevitable in scaling
up or was dilution because one was implemented by
the government and the other by an NGO, or was
size/scale the problem? What design changes were
necessary to ensure effective scaling up within the
government system or on a larger scale?
Deliberating on the issue of dilution in quality when
an intervention was scaled up, Dr. Sundararaman said
that some of the problems that led to dilution were:
• The question of motivated leadership, that is, “one
could do it in Jamkhed or in Mandwa, but how could
one get an Arole or an Antia or an Abhay Bang in
every place?”
• The quality of training. There was a problem of
transmission loss in the training cascade
• The quality of trouble shooting. On the job support
was very important and often lacking
• The quality of monitoring. There was a need for a
system that not only identified the weak areas but
responded to them
• The quality of referral support in the CHW
programme. There was a need for institutional
Dr. T. Sundararaman, National Health Systems Resource Centre
structures that played higher order roles to
complement and later sustain the programme
• The ability to adopt a tradition of working with the
local community
• An ability to persist, learn and correct
• The lack of a scientifically sound evaluation
methodology that could provide useful lessons to
strengthen and improve the programme
He stated that while scaling up the Mitanin Programme
there were a number of lessons learnt that provided
insight into some of these issues of dilution in quality.
The first lesson, Dr. Sundararaman said, was that
changing the size or scale of the programme meant
making changes in the design of every component of the
programme to cater to the expanded scale. Explaining
the point with examples from the programme he said,
that in the NGO model of the Mitanin programme, the
voluntary workforce of women was supported by a
very good base hospital with a medical team. However,
when scaled up within the government system, the
role of a ‘referral hospital back up’ had to be played
by the PHCs and CHCs. This was initially seen as a
problem, but the change was adopted and viewed as
part of the larger health sector reform process.
Dr. Sundararaman said the absence of community
involvement within government systems and
administrative functioning, which was the core of
the Mitanin Programme, also posed as a barrier.
While NGO programmes were able to reach out to
the community, government efforts tended to be
in the mode of official communiqués. He said, to
overcome this problem and institutionalize within the
government, individuals who would articulate the
voice of the weak, trained facilitators or preraks were
introduced. The preraks were meant to undertake a
process of social mobilization through mediums such
as songs and plays that would bring out the spirit of
the programme among the community for whom it
was meant. This was an example, Dr. Sundararaman
said, of the emergence of a need for an intermediary
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force while scaling up. This need however, brought
with it a new set of problems in terms of required
supervision and support structures for preraks. Thus
every change, or modification in design, had a resultant
impact which needed to be considered if the change
was to be effective.
Another key learning in the process of scaling up, Dr.
Sundararaman said, was the relevance of pacing a
programme while scaling it up. This was necessary
to ensure enough time for a minimum set of well
defined processes/structures to be established and
also to ensure that these were accompanied with
constant corrections and innovations. It was therefore
essential, he said, to stagger the programme in atleast
four phases:
• First Phase – building the tools and building the
State leadership
• Second Phase - building the district teams,
getting the systems in place
• Third Phase - reaching out to full coverage
• Subsequent Phases - re-doing various aspects,
bringing in corrections, innovations etc.
Dr. Sundararaman asserted that successful scaling
up to a large extent was dependent on the capacity
building of the functionaries. Therefore, effort to
address the inevitable transmission loss in training
cascades was necessary. This required capable full
time key resource persons who were hand-picked
and personally trained. It also required systematic
development and use of training material and use of
training evaluation. Giving the example of the Mitanin
Programme he said focused efforts had been made
under the programme to develop a strong training
cadre. The result was that today there were over 3000
trainers, 300 district trainer resource persons and 25
State trainers.
Equally significant in scaling up, Dr. Sundararaman
stated, was the monitoring strategy. While the NGO
model primarily relied on review meetings, there was
a need for a much more systematized approach in the
scaled up programme. It required:
• Putting in place a set of defined processes - the cluster
meeting, the block trainers review meeting, the
district coordination meeting, the State nodal officers
review meeting, the State field coordinators review
meeting
• Putting in place a large workforce of trainers, field
coordinators etc. to do this
• Developing key indicators for monitoring both
processes and outcomes
Dr. Sundararaman concluded his presentation by
highlighting the need for effective evaluation in
ensuring successful scaling up. He stated that within
the constraints of the government system, the best
way forward was undertaking an internal evaluation
with in-built externality and key processes under
qualitative study.
Concluding Remarks from the Chair: The
Chairperson of the session Dr. Narendra Jadhav,
Member, Planning Commission, emphasised the
importance of data collection in evidence building and
added light heartedly that “if one tortured the data
long enough, it would confess anything”. He said
that all the community based models showed that
communities were geared to scale up. Some examples
of how this could be done in the field was through
alternative delivery mechanisms like SHGs and PRIs.
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
Snippets from participant discussions.
‘The method of having sentinel sites for monitoring models and innovations should be adopted.’
Dr. Prasanta Tripathy, Ekjut
‘The main concern is that not enough is being done to convert evidence into policy and programmes as
it should be done ideally. A lot more effort needs to be made for undertaking ongoing evaluation of the
National Rural Health Mission.’
Dr. Prathap Tharyan, South Asian Cochrane Network and Centre
‘One pilot study is not enough to scale up a model. More than one piece of evidence, showing the pilot
works, is required before a pilot should be scaled up. People implementing pilots should not just put M&E
systems in place but also publish the findings from these systems and put them up for public review.’
Dr. Tracy Koehlmoos, ICDDR, Bangladesh
‘Evidence has to be looked at throughout the process of scaling up. While the need for schemes like JSY
emerged from evidence which suggested that skilled birth attendants and EmOC services helped reduce
maternal deaths, evidence was not used in designing the scheme itself. There is a need to get evidence
even while something is being implemented. We need to convince the government that it is critical to build
in evaluation in the design of the programme at every step of the way.’
Marta Levitt Dayal, MCH-STAR
‘When a pilot is scaled up it loses its teeth. To prevent this loss, competition should be generated by asking
different stakeholders to implement the pilot in different blocks. For example, one block should be given to
an NGO, another to a corporate and another can be run by the government. This would generate a healthy
competition between the three and ensure there is no loss in intensity of efforts.’
Col. S. Rath, KGVK and Citizens Foundation
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
5. Concluding Session: The Way Forward
In the concluding session, Ms. Poonam Muttreja,
Country Director, MacArthur Foundation and Dr.
Richard Kohl, Technical Director and Project Director,
Scaling Up, MSI, requested participants to suggest
possible ways in which to make the process of scaling
up, in the domain of health, sustainable.
Dr. Kohl initiated the discussion by sharing some
insights that emerged from the day’s deliberations. He
said the most promising models or innovations in the
health sector seemed to be community based models.
This was a challenge as the only existing system with
the capacity to implement on a large scale was the
government system, which was inept at community
mobilisation. This, he said, made successful large
scale implementation of these models challenging.
While pointing out possible alternate delivery
mechanisms like PRIs, civil society organisations, SHGs
etc. which had expertise in community mobilisation,
Dr. Kohl stated that there were challenges related to
these alternate mechanisms as well. Issues of funding
and maintaining transparency and accountability of
these organisations had to be addressed. In addition,
the government still needed to play the role of a
facilitator and maintain responsibility for ensuring
implementation. The Karuna Trust model, he said,
was a perfect example of government collaboration
with civil society, wherein the government remained
responsible for delivering health services even
while handing over implementation to a civil society
organisation.
Highlighting the issue of evidence-based
implementation, Dr. Kohl said there was a need for
designing effective monitoring and evaluation in trials
of alternative models of implementation and not just
at the intervention level. Randomised control trials
tended to be done at the intervention level, whereas
there was a need for such evidence based support at
the implementation level as well.
Participants added to this dialogue by sharing the
following thoughts:
• For scaling up community mobilisation models and
processes there was a need for the government
to create an enabling environment for community
mobilisation through civil society organisations.
Processes of community engagement were
impactful on health outcomes as well as in creating
an equalising environment
• Civil society engagement could focus on the
most underserved areas, instead of focusing on
implementation at a large scale. Underserved
areas could be handed over by the government to
civil society and perhaps even the private sector.
However, the scope and nature of private sector
engagement needed to be thought through
• Effective scaling up was only possible if serious
attention was given to capacity building of field
functionaries as well as programme management
staff. For example, effective implementation of the
ASHA programme was possible only if they were
well trained
• Bringing about collaboration and cooperation
between different ministries in the social sector
would facilitate any endeavour to scale up
Thanking the participants for their valuable thoughts
and suggestions, Ms. Muttreja said there was a need
for greater understanding and further discussion to
ensure efforts at scaling up became effective and
sustainable. Concluding the conference she expressed
the hope that the dialogue on scaling up within the
social sector, and especially the health sector, would
continue beyond the conference doors with key
government officials and civil society professionals.
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
6. Conference Summary:
Some Key Questions Raised
The Conference raised some key questions which need to be answered in order to make the process of scaling
up sustainable:
• Given the reality that scaling up is sensitive to individual personalities and leadership, how can the process of
scaling up be made sustainable in the event of leadership change?
• What are the ways to rise above the desire of every agency to have a strong ownership for their model and
adapt, accommodate and incorporate other processes in the larger interests of sustainability?
• How can an organization’s institutional capacity be strengthened to include scaling up in its designing process,
at the implementation stage as well as in transferring knowledge to the large scale implementer?
• How can the scaling up process integrate with a policy friendly environment? What is required to build a
commitment among the government and donors towards adoption of a pro-active approach to scaling up?
• How critical is the role of an intermediary agency to support scaling up, particularly in planning for scaling up
and in its implementation?
• Are there ways to simplify the framework and the processes of scaling up which ideally begin from the
designing stage of the project and continue during and post implementation?
PFI with support from the MacArthur Foundation and Management Systems International hopes to work towards
answering some of these questions and making scaling up not just another word in the development lexicon but
a potential reality.
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Annexures
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
Annexure 1: Conference Agenda
National Conference
Scaling Up in India: Lessons Learnt and Way Forward
19 April 2010
Venue: Gulmohar Hall, India Habitat Centre, New Delhi
Time
9:30 AM – 10:00 AM
10:00 AM – 11:00 AM
11:00 AM – 11:30 AM
11:30 AM - 1:00 PM
1:00 PM—2:00 PM
Registration
Session Details
Inaugural Session
Welcome Address
Ms. Poonam Muttreja, Country Director, MacArthur Foundation
Presentations:
Scaling Up: Objectives and Background - Mr. A.R. Nanda,
Executive Director, Population Foundation of India
The Scaling Up Management Framework and Lessons Learnt
- Dr. Richard Kohl and Dr. Rajani Ved, Management Systems
International
Inaugural Address: Mr. Arun Maira, Member, Planning Commission,
Government of India
Tea Break
Session 1: Scaling Up through Government Systems
Chairperson: Mr. Arun Maira, Member, Planning Commission,
Government of India
Panelists:
Scaling up: Perspectives of the Planning Commission - Ms. Sudha
Pillai, Secretary, Planning Commission, Government of India
Global Experience: Learnings in Scaling Up - Mr. Larry Cooley,
President, Management Systems International
Issues of Gender and Rights in Scaling Up - Dr. A. K. Shiva
Kumar, Development Economist
Discussion
Lunch Break
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
2:00 PM – 3:30 PM
3:30 PM – 3:45 PM
3:45 PM – 5:00 PM
5:00 PM – 5:30 PM
Session 2: Experiences of Scaling Up
Chairperson: Dr. Syeda Hameed, Member, Planning Commission,
Government of India
Presentations:
Home Based Newborn and Child Care - Dr. Abhay Bang, SEARCH
A Public-Private-Partnership model of Primary Health Centre
(PHC) Management - Dr. H. Sudarshan, Karuna Trust
Community Based Micro-Insurance - Ms. Mirai Chatterjee, Vimo SEWA
Improving Child Nutrition in India - Mr. K.S. Murthy, Bhavishya
Alliance
Discussion
Tea Break
Session 3: Role of Monitoring & Evaluation and Evidence
Building in Scaling Up
Chairperson: Dr. Narendra Jadhav, Member, Planning Commission,
Government of India
Presentations:
• Cochrane Reviews: Evidence Building for Scaling Up – Dr. Prathap Tharyan,
Director, South Asia Cochrane Centre and Network, Vellore
• The BRAC Experience in Scaling Up - Dr. Richard Cash, Harvard School of
Public Health
• Evidence Building in Scaling Up of the ASHA Programme -
Dr. T. Sundararaman, Executive Director, NHSRC
Discussion
Concluding Session: The Way Forward
Panelists:
• Ms. Poonam Muttreja, Country Director, MacArthur Foundation
• Dr. Richard Kohl, Technical Director and Project Director, Scaling Up,
Management Systems International
• Mr. A. R. Nanda, Executive Director, Population Foundation of India
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
Annexure 2: Media Reports
Pilot projects in social sector
By IANS
April 19th, 2010
inefficient, say experts
NEW DELHI - Pilot projects which the
government often resorts to in order to
test the efficacy of what can become
a potentially big scheme, hardly serves
any purpose and dissipates in no time
despite showing promise initially,
experts said.
Sudha Pillai, Secretary of the Planning
Commission while talking at the con-
ference ‘Scaling up in India: Lessons
Learnt and Way Forward’ Monday said:
“A pilot project is a seductive concept.
You have limited money and a hand-
ful of people to implement it. The initial
results may be fabulous, but the effect
does not last.”
Larry Cooley, president of Management
Systems International, an international
development consulting firm similarly
said that most pilot projects fail to
serve their purpose - to be scaled up
after a certain period.
“If the motive is to scale up after
implementation of a pilot project, then
clearly a lot of them are failing because
they simply disappear after the initial
promising results. The reason is that
most of these projects don’t include
strategies to scale up,” Cooley said.
Pillai said: “To be more effective,
the government should take more
initiatives, go for more discussions
and embark upon large schemes in
the social sector which cover the
country and has provisions for areas
with special needs like scheduled caste
majority areas,” she added.
Taking the example of the government’s
flagship scheme for better healthcare,
the National Rural Health Mission
(NRHM), Pillai went on to say that
workshops should be held before
implementing big schemes in order to
ensure their efficacy.
Pillai further said: “Most of the pi-
lot projects are dependent on donor
agencies for finances, but we forget
that these agencies are not going
to be around forever to help. There-
fore instead of becoming something
big, pilot projects remain just what
they are”.
New Delhi |Monday, 2010 6:05:06 PM IST
Netindia123.com
Pilot projects which the government
often resorts to in order to test the
efficacy of what can become a poten-
tially big scheme, hardly serves any
purpose and dissipates in no time de-
spite showing promise initially, experts
said.
Sudha Pillai, secretary of the planning
commission while talking at the con-
ference ‘Scaling up in India: Lessons
Learnt and Way Forward’ Monday said:
“A pilot project is a seductive concept.
You have limited money and a handful
of people to implement it. The initial
results may be fabulous, but the effect
does not last.”
Larry Cooley, president of Manage-
ment Systems International, an inter-
national development consulting firm
similarly said that most pilot projects
fail to serve their purpose - to be
scaled up after a certain period.
“If the motive is to scale up after im-
plementation of a pilot project, then
clearly a lot of them are failing because
they simply disappear after the initial
promising results. The reason is that
most of these projects don’t include
strategies to scale up,” Cooley said.
Pillai said: “To be more effective, the
government should take more initia-
tives, go for more discussions and em-
bark upon large schemes in the social
sector which cover the country and
has provisions for areas with special
needs like scheduled caste majority
areas,” she added.
Taking the example of the govern-
ment’s flagship scheme for better
healthcare, the National Rural Health
Mission (NRHM), Pillai went on to say
that workshops should be held before
implementing big schemes in order to
ensure their efficacy.
Pillai further said: “Most of the pi-
lot projects are dependent on donor
agencies for finances, but we forget
that these agencies are not going to
be around forever to help. Therefore
instead of becoming something big,
pilot projects remain just what they
are”.
azr/vdm/dg
www.khabrein.info/news/Pilot_proj-
ects_in_social_sector_inefficient__
say_experts_1271680332
www.inditop.com/.../pilot-projects-in-
social-sector-inefficient-say-experts
www.prokerala.com/news/articles/
a129604.html
www.mynews.in/News/Pilot_projects_
in_social_sector_inefficient,_say_ex-
perts_N48027.html
www.india-forums.com/news/article.
asp?id=242623
in.news.yahoo.com/.../20100419/.../
tnl-pilot-projects-in-social-sector-inef.
www.aol.in/news-story/pilot-projects-
in-social-sector.../874769
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National Conference – Scaling Up in India: Lessons Learnt and Way Forward
Indian Express (New Delhi)
Tenacity needed to scale
up health projects’
Express News Service Posted online:
Tuesday, Apr 20, 2010 at 0114 hrs
New Delhi : Health interventions
initiated by community-based
organisations like self help groups
and Panchayati raj can be scaled up
effectively only if the government
ensures that the most vulnerable
communities get these services.
Speaking at a national conference on
“Scaling up in India: Lessons Learnt And
The Way Forward” held in the Capital,
experts maintained that several public
private partnerships such as running
primary health centres in the backward
areas of the country have established
the possibility of their being scaled
up with government support. The
participants at the conference including
Planning Commission Members, NGOs
and health activists, also discussed
challenges of scaling up innovative
health schemes.
According to Planning Commission
member Dr Syeda Hameed, the
Commission is engaged in discussions
with chief ministers of various states
on the 12th Plan and these models
would be considered for replication in
the other states.
Secretary of the Planning Commission,
Sudha Pillai, said there were challenges
in expanding small successful pilot
initiatives into largescale government
supported programmes. “One size does
not fit all. Specific problems needed
specific solutions,” she said. “Even in a
national programme like the National
Rural Health Mission, discussions are
on to bring in local perspectives,”
said Dr Arun Maira, Member, Planning
Commission.
An example quoted was of a
programme for neonatal survival run
by SEARCH, a NGO in Gadchiroli,
Maharashtra. “The program began
from ‘home-based newborn care’ to
‘home-based maternal, newborn, and
child healthcare. This helped SEARCH
to expand their project to seven
districts of Karnataka and to countries
in South Asia and Africa,” Dr Abhay
Bang, the founder of SEARCH, said.
Faraz Ahmad/Tribune News Service
Conference to review health
interventions by NGOs today
A national conference to look at the
replication and scaling up of four
successful health interventions by
NGOs in Karnataka, Maharashtra
and Gujarat is being organised by
the Planning Commission, Population
Foundation of India, MacArthur
Foundation and Management Systems
International (MSI) at the India Habitat
Centre tomorrow.
Four projects under scrutiny for further
up scaling are ‘Home based newborn
and child care’ by Dr Bang’s SEARCH
in Gadchiroli, Maharashtra; ‘Public-
private partnership model of primary
health centre (PHC) Management’
by Dr Sudershan’s Karuna, Trust in
the Biligirirangan Hills of Karnataka;
‘Community based micro-insurance’ by
Vimo SEWA in Gujarat and ‘Improving
child nutrition’ by KS Murthy’s
Bhavishya Alliance in Maharashtra.
These projects have demonstrated
that a sea change is possible in public
health in rural India with committed
and effective interventions. Some
of the projects have already been
replicated in other states.
The Karuna Trust has been running 26
PHCs in Karanataka and 22 others in
Andhra Pradesh, Arunachal Pradesh,
Orissa and Meghalaya. Established
in 1986, the Karuna Trust had its
origins in the work and experience of
Vivekananda Girijana Kalyana Kendra
(VGKK), an NGO providing basic
health care to tribal communities
from BR Hills, Chamarajnagar district
of Karnataka. When VGKK extended
its health services to tribals outside
BR Hills through a clinic at Yelandur
Taluka at its foothills, it discovered a
hyper endemic prevalence of leprosy
in the taluka. The manner in which
the Trust dealt with leprosy, led the
Karnataka government handing over
the day-to-day management of the
PHC at Gumballi to the Trust.
The Home Based Newborn and Child
Care (HBNCC) model of SEARCH was
originally piloted in Gadchiroli district
of Maharashtra. Later, it was tested in
seven districts of Maharashtra through
NGOs (Ankur project) and is being
implemented under a five-site multi-
centric study through ICMR in five
states - Bihar, Maharashtra, Orissa,
Rajasthan and Uttar Pradesh.
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POPULATION FOUNDATION OF INDIA
B-28, Qutab Institutional Area, New Delhi- 110016
Tel.: +91-11-43894100, Fax: +91-11-43894199
E-mail: popfound@sify.com, Website : www.popfound.org