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“Achieving the Sustainable Development Goals in health and well-being requires scaling up successfully tested interventions that catalyze communities to reflect on and challenge existing social norms that lead to poor sexual and reproductive health among adolescents and youth. Unfortunately many pilot projects are conducted but few are scaled up.”

This brief looks at the lessons learned from the Gender Roles, Equality and Transformations (GREAT) Project, offering insights into the art and science of implementing, documenting, and evaluating scale-up. The USAID-funded project was a six-and-a-half year implementation research and delivery science initiative to develop, test, and scale up an intervention aimed at promoting gender equality, reducing gender-based violence (GBV), and improving sexual and reproductive health (SRH) among adolescents in post-conflict communities northern Uganda. It was implemented by the Institute for Reproductive Health at Georgetown University, Pathfinder International, and Save the  Children.

The project developed and tested life-stage specific strategies to promote gender-equitable attitudes and behaviours among adolescents and their communities using a set of participatory activities to engage adolescents and adults in discussion and reflection about violence, gender inequality, and sexual and reproductive health. GREAT activities include: 1) Community Action Cycle: simple steps to bring communities together to take action to improve adolescent well-being; 2) Radio Drama: a serial drama with stories and songs about young people and their families living in Northern Uganda; 3) Village Health Team (VHT) Service Linkages: orientation to help VHTs offer adolescent-friendly services; and 4) A toolkit for community groups and school-based clubs: engaging stories and lively activities and games. Materials were targeted to four life stage cohorts (10-14 year olds, older adolescents 15-19 years old, newly married and/or parenting adolescents 15-19 years old, and adults). (See Related Summaries below for more information)

GREAT’s scale-up approach was based on the World Health Organization (WHO) ExpandNet Model, which defines scale-up as “the implementation of deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis.” GREAT was designed for scale from inception and therefore met the criteria a project needs to be scaled up (which are described in the brief).  The two major aims of the scale-up phase were to: 1) Build the capacity of organisations with widespread coverage in Northern Uganda to incorporate elements of GREAT into their programmes; and 2) to expand the GREAT package throughout selected districts with the goal of reaching a tipping point to bring about sustainable change in gender norms to promote long-term SRH improvements. The scale- up was both horizontal in that it sought to expand to new geographic areas, as well as vertical, which sought to institutionalise the approach within government departments.

The brief describes the scale up process, which involved the following: 1) developing and monitoring GREAT implementation; 2) developing key documentation to provide a roadmap for organisations seeking to use the approach (a Monitoring, Learning, and Evaluation (MLE) Handbook and How-to Guide); 3) integrating into programmes through an iterative, participatory process involving stakeholders; 4) building and supporting capacity for ongoing efforts; and 5) evaluating fidelity to the intervention, feasibility of implementation/capacity, and institutionalisation throughout the process.

The brief outlines the results of the scale up according to: fidelity and quality of implementing the GREAT components (coverage of radio drama, exposure to toolkit, and awareness of community action cycle activities); feasibility/capacity of others to implement; and institutionalisation.  In brief, the evaluation results showed that the approach was integrated into 35 user organisations maintaining core values/quality. The results also demonstrated a capacity to offer the package independently with limited financial support; and in terms of institutionalisation, NGOs and districts incorporated the approach into new projects, and new organisations were trained to implement the approach. Overall, the “[E]valuation of the scale-up phase concluded that with a supply of intervention materials, along with orientation, training, and modest financial support, user organizations can adopt and introduce GREAT into existing program activities. However, coverage - and most likely effectiveness - would be greater with more resources.” The process of scaling up GREAT highlighted the following key lessons about the nuances of scale-up:

  • Use lean materials and strategy that are affordable to produce and can be used with minimal orientation and coaching.
  • Create easy to use documentation - Develop ‘how-to’ guides that systematise staff orientation to core concepts, provide step-by-step implementation guidance, include approaches to monitor fidelity, quality and adherence to values, and explain how to adapt interventions for new contexts.
  • Invest in your resource team - Capacity of the resource team to provide orientation, training, and support to new user organisations was critical. They needed to navigate the internal systems of other organisations, for example using their work plans to identify needs and provide appropriate assistance.
  • Support ongoing collaboration and capacity building - Ongoing check-ins and coordination and reflection meetings provided opportunities for the user organisations and districts to share activity updates, lessons learned, and work plans for the coming quarter. Particularly useful were supportive supervision visits and capacity assessments with user organisations.
  • Integrate into another institutional efforts - Collaboration and capacity building helped GREAT integrate activities into other institutional efforts. Having regular check in points with participatory decision-making and sharing information with line ministries and the technical advisory group helped develop a shared scale-up mindset among all participating groups and fostered integration.
  • Be attentive to external factors affecting scale up such as environmental and financial constraints, as this can impede successful scale-up.
  • Leverage global resources - Donor engagement and support was critical to maintaining momentum and the use of strategic communication and dissemination leveraged global resources on adolescent SRH, GBV and gender equality.

IRH website on September 6 2017.