Commentary: Managing scaling up: what are the key issues?

We want to pick up and expand on two sets of interrelated issues raised in the paper by Mangham and Hanson (2010): the importance of political commitment and of strategic management to scaling up. As the paper makes clear, these issues are integral to successful scaling up. Evidence on progress towards the Millennium Development Goals, for example, demonstrates the need for strong government leadership, whilst policy and strategic management is one of the five barriers recognized to constrain expansion of health interventions' coverage. But, as the paper also shows, within scaling up debates little attention has so far been paid either to how to generate political commitment to scale up public health interventions, or to the nature of the strategic management also required to support this process. Yet there is (some) relevant health evidence, as well as relevant theory, around policy implementation (e.g. Hill and Hupe 2002) and innovation (Greenhalgh et al. 2004), from which to draw useful insights. First, we look at political commitment. For low-and middle-income settings there is a relatively rich body of empirical work examining how policy agendas are set, including the transfer of policy ideas between international and national jurisdictions (Gilson and Raphaely 2008). This work critiques the idea that political will is the central determinant of successful policy change (Reich 1995). Instead, it shows how political commitment to a new policy or programme has to be actively created, essentially through advocacy. Examining maternal health policy experience, Shiffman (2007) highlights the importance of alliance building to consolidate influence, working with political entrepreneurs to get public health issues onto policy agendas, using credible measures to demonstrate the severity of the problem addressed through a new programme and avoid denial of its importance, organizing focusing events to publicize the issue and presenting policy makers with policy alternatives of proven effectiveness which show them the problem can be addressed. These sorts of advocacy efforts may also be important once an issue or programme is on the policy agenda, to secure sustained domestic budgetary commitments (Crichton 2008). When international actors seek to influence national policy agendas, they are, therefore, likely to be more effective when they work as advocates of change rather than adopting more coercive approaches (Walt et al. 2004). Second, managing scaling-up processes. Although the precepts of rational planning (such as developing objectives and resource requirements, prioritizing activities, sequencing implementation and monitoring and evaluation) are important when …