Scaling up with other HIV interventions and services
Q.34 How national and district health authorities can systematically scale up while repeatedly learning and improving processes
Implementing new and comprehensive interventions, such as integrating provision of ARVs with breastfeeding support, is complex, and there is presently little relevant programmatic experience outside a few research settings.
It makes sense to rapidly test and learn the best way to implement a system that successfully links the two main interventions, i.e. ARV prophylaxis or treatment and support for infant feeding, before scaling up to all sites nationally. This process can generate valuable insights that in turn can be used to guide implementation in a large number of sites. Such testing is usually best conducted in relatively well-functioning sites that can implement, assess, interpret and modify approaches until a more effective system is developed. Sites that test approaches should represent functional units within district health systems, such as a district hospital and associated referral clinics - not isolated clinics or hospitals.
Scaling up effective implementation approaches can then be spread to larger numbers of functional units and then to the entire system. Such approaches require reliable local data to reflect how well services are delivered. A limited number of indicators (3 - 4) based on local routine data should be selected and used on a regular basis to inform the effectiveness of implementation. These data-driven approaches should be used as a means of identifying solutions and monitoring progress. Health workers and local managers are often concerned that such approaches might be used to 'judge' their performance and might negatively impact on them individually. This issue should be dealt with by their supervisors, who should practise supportive supervision.