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Background: Ever since Ghana embraced the 1978 Alma-Ata Declaration, it has consigned priority to achieving ‘Health for All.’ The Community-based Health Planning and Services (CHPS) Initiative was established to close gaps in geographic access to services and health equity. CHPS is Ghana’s flagship Universal Health Coverage (UHC) Initiative and will soon completely cover the country with community-located services. Objectives: This paper aims to identify community perceptions of gaps in CHPS maternal and child health services that detract from its UHC goals and to elicit advice on how the contribution of CHPS to UHC can be improved. Method: Three dimensions of access to CHPS care were investigated: geographic, social, and financial. Focus group data were collected in 40 sessions conducted in eight communities located in two districts each of the Northern and Volta Regions. Groups were comprised of 327 participants representing four types of potential clientele: mothers and fathers of children under 5, young men and young women ages 15–24. Results: Posting trained primary health-care nurses to community locations as a means of improving primary health-care access is emphatically supported by focus group participants, even in localities where CHPS is not yet functioning. Despite this consensus, comments on CHPS activities suggest that CHPS services are often compromised by cultural, financial, and familial constraints to women’s health-seeking autonomy and by programmatic lapses constrain implementation of key components of care. Respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services. Conclusion: Improving geographic and financial access to CHPS facilities is essential to UHC, but responding to community need for improved outreach, and service quality is equivalently critical to achieving this goal.

Background: Ever since Ghana embraced the 1978 Alma-Ata Declaration, it has consigned priority to achieving ‘Health for All.’ The Community-based Health Planning and Services (CHPS) Initiative was established to close gaps in geographic access to services and health equity. CHPS is Ghana’s flagship Universal Health Coverage (UHC) Initiative and will soon completely cover the country with community-located services. Objectives: This paper aims to identify community perceptions of gaps in CHPS maternal and child health services that detract from its UHC goals and to elicit advice on how the contribution of CHPS to UHC can be improved. Method: Three dimensions of access to CHPS care were investigated: geographic, social, and financial. Focus group data were collected in 40 sessions conducted in eight communities located in two districts each of the Northern and Volta Regions. Groups were comprised of 327 participants representing four types of potential clientele: mothers and fathers of children under 5, young men and young women ages 15–24. Results: Posting trained primary health-care nurses to community locations as a means of improving primary health-care access is emphatically supported by focus group participants, even in localities where CHPS is not yet functioning. Despite this consensus, comments on CHPS activities suggest that CHPS services are often compromised by cultural, financial, and familial constraints to women’s health-seeking autonomy and by programmatic lapses constrain implementation of key components of care. Respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services. Conclusion: Improving geographic and financial access to CHPS facilities is essential to UHC, but responding to community need for improved outreach, and service quality is equivalently critical to achieving this goal. [ABSTRACT FROM AUTHOR]

Policy-makers worldwide are increasingly interested in scaling up evidence-based interventions (EBIs) to larger populations, and implementation scientists are developing frameworks and methodologies for achieving this. But scaling-up does not always produce the desired results. Why not? We aimed to enhance awareness of the various pitfalls to be anticipated when planning scale-up. In lower- and middle-income countries (LMICs), the scale-up of health programs to prevent or respond to outbreaks of communicable diseases has been occurring for many decades. In high-income countries, there is new interest in the scaling up of interventions that address communicable and non-communicable diseases alike. We scanned the literature worldwide on problems encountered when implementing scale-up plans revealed a number of potential pitfalls that we discuss in this paper. We identified and discussed the following six major pitfalls of scaling-up EBIs: 1) the cost-effectiveness estimation pitfall, i.e. accurate cost-effectiveness estimates about real-world implementation are almost impossible, making predictions of economies of scale unreliable; 2) the health inequities pitfall, i.e. some people will necessarily be left out and therefore not benefit from the scaled-up EBIs; 3) the scaled-up harm pitfall, i.e. the harms as well as the benefits may be amplified by the scaling-up; 4) the ethical pitfall, i.e. informed consent may be a challenge on a grander scale; 5) the top-down pitfall, i.e. the needs, preferences and culture of end-users may be forgotten when scale-up is directed from above; and 6) the contextual pitfall, i.e. it may not be possible to adapt the EBIs to every context. If its pitfalls are addressed head on, scaling-up may be a powerful process for translating research data into practical improvements in healthcare in both LMICs and high-income countries, ensuring that more people benefit from EBIs.

Policy-makers worldwide are increasingly interested in scaling up evidence-based interventions (EBIs) to larger populations, and implementation scientists are developing frameworks and methodologies for achieving this. But scaling-up does not always produce the desired results. Why not? We aimed to enhance awareness of the various pitfalls to be anticipated when planning scale-up. In lower- and middle-income countries (LMICs), the scale-up of health programs to prevent or respond to outbreaks of communicable diseases has been occurring for many decades. In high-income countries, there is new interest in the scaling up of interventions that address communicable and non-communicable diseases alike. We scanned the literature worldwide on problems encountered when implementing scale-up plans revealed a number of potential pitfalls that we discuss in this paper. We identified and discussed the following six major pitfalls of scaling-up EBIs: 1) the cost-effectiveness estimation pitfall, i.e. accurate cost-effectiveness estimates about real-world implementation are almost impossible, making predictions of economies of scale unreliable; 2) the health inequities pitfall, i.e. some people will necessarily be left out and therefore not benefit from the scaled-up EBIs; 3) the scaled-up harm pitfall, i.e. the harms as well as the benefits may be amplified by the scaling-up; 4) the ethical pitfall, i.e. informed consent may be a challenge on a grander scale; 5) the top-down pitfall, i.e. the needs, preferences and culture of end-users may be forgotten when scale-up is directed from above; and 6) the contextual pitfall, i.e. it may not be possible to adapt the EBIs to every context. If its pitfalls are addressed head on, scaling-up may be a powerful process for translating research data into practical improvements in healthcare in both LMICs and high-income countries, ensuring that more people benefit from EBIs. [ABSTRACT FROM AUTHOR]

Background: North-South Partnership (NSP) is the mandated blueprint for much global health action. Northern partners contribute funding and expertise and Southern partners contribute capacity for local action. Potential Northern partners are attracted to Southern organizations that have a track record of participating in well-performing NSPs. This often leads to the rapid ‘scaling up’ of the Southern organization's activities, and more predictable and stable access to resources. Yet, scaling up may also present challenges and threats, as the literature on rapid organization growth shows. However, studies of the impact of scaling up within NSPs in particular are absent from the literature, and the positive and negative impact of scaling up on Southern partners’ functioning is a matter of speculation. Objective: The purpose of this study is to examine how scaling up affects a Southern partner's organizational functioning, in a Southern grassroots NGO with 20 years of scaling up experience. Design: A case study design was used to explore the process and impact of scaling up in KIWAKKUKI, a women's grassroots organization working on issues of HIV and AIDS in the Kilimanjaro region of Tanzania. Data included documents, observation notes and in-depth interviews with six participants. The data were analyzed by applying an established systems framework of partnership functioning, in addition to a scaling up typology. Results: KIWAKKUKI has experienced significant scale-up of activities over the past 20 years. Over time, successful partnerships and programs have created synergy and led to further growth. As KIWAKUKKI expanded so did both its partnerships and grassroots base. The need for capacity building for volunteers exceeded the financial resources provided by Northern partners. Some partners did not have such capacity building as part of their own central mission. This gap in training has produced negative cycles within the organization and its NSPs. Conclusions: Northern partners were drawn to KIWAKKUKI because of its strong and rapidly growing grassroots base, however, a lack of funding has led to inadequate training for the burgeoning grassroots. Opportunity exists to improve this negative result: Northern organizations that value community engagement can purposefully align their missions and funding within NSP to better support grassroots efforts, especially through periods of expansion.

Background: North-South Partnership (NSP) is the mandated blueprint for much global health action. Northern partners contribute funding and expertise and Southern partners contribute capacity for local action. Potential Northern partners are attracted to Southern organizations that have a track record of participating in well-performing NSPs. This often leads to the rapid 'scaling up' of the Southern organization's activities, and more predictable and stable access to resources. Yet, scaling up may also present challenges and threats, as the literature on rapid organization growth shows. However, studies of the impact of scaling up within NSPs in particular are absent from the literature, and the positive and negative impact of scaling up on Southern partners' functioning is a matter of speculation. Objective: The purpose of this study is to examine how scaling up affects a Southern partner's organizational functioning, in a Southern grassroots NGO with 20 years of scaling up experience. Design: A case study design was used to explore the process and impact of scaling up in KIWAKKUKI, a women's grassroots organization working on issues of HIV and AIDS in the Kilimanjaro region of Tanzania. Data included documents, observation notes and in-depth interviews with six participants. The data were analyzed by applying an established systems framework of partnership functioning, in addition to a scaling up typology. Results: KIWAKKUKI has experienced significant scale-up of activities over the past 20 years. Over time, successful partnerships and programs have created synergy and led to further growth. As KIWAKUKKI expanded so did both its partnerships and grassroots base. The need for capacity building for volunteers exceeded the financial resources provided by Northern partners. Some partners did not have such capacity building as part of their own central mission. This gap in training has produced negative cycles within the organization and its NSPs. Conclusions: Northern partners were drawn to KIWAKKUKI because of its strong and rapidly growing grassroots base, however, a lack of funding has led to inadequate training for the burgeoning grassroots. Opportunity exists to improve this negative result: Northern organizations that value community engagement can purposefully align their missions and funding within NSP to better support grassroots efforts, especially through periods of expansion. [ABSTRACT FROM AUTHOR]