Assessing the scalability of a health management-strengthening intervention at the district level: a qualitative study in Ghana, Malawi and Uganda

BACKGROUND: The scale-up of successfully tested public health interventions is critical to achieving universal health coverage. To ensure optimal use of resources, assessment of the scalability of an intervention is recognized as a crucial step in the scale-up process. This study assessed the scalability of a tested health management-strengthening intervention (MSI) at the district level in Ghana, Malawi and Uganda. METHODS: Qualitative interviews were conducted with intervention users (district health management teams, DHMTs) and implementers of the scale-up of the intervention (national-level actors) in Ghana, Malawi and Uganda, before and 1 year after the scale-up had started. To assess the scalability of the intervention, the CORRECT criteria from WHO/ExpandNet were used during analysis. RESULTS: The MSI was seen as credible, as regional- and national-level Ministry of Health officials were championing the intervention. While documented evidence on intervention effectiveness was limited, district- and national-level stakeholders seemed to be convinced of the value of the intervention. This was based on its observed positive results regarding management competencies, teamwork and specific aspects of health workforce performance and service delivery. The perceived need for strengthening of management capacity and service delivery showed the relevance of the intervention, and relative advantages of the intervention were its participatory and sustainable nature. Turnover within the DHMTs and limited (initial) management capacity were factors complicating implementation. The intervention was not contested and was seen as compatible with (policy) priorities at the national level. CONCLUSION: We conclude that the MSI is scalable. However, to enhance its scalability, certain aspects should be adapted to better fit the context in which the intervention is being scaled up. Greater involvement of regional and national actors alongside improved documentation of results of the intervention can facilitate scale-up. Continuous assessment of the scalability of the intervention with all stakeholders involved is necessary, as context, stakeholders and priorities may change. Therefore, adaptations of the intervention might be required. The assessment of scalability, preferably as part of the monitoring of a scale-up strategy, enables critical reflections on next steps to make the intervention more scalable and the scale-up more successful.