Scaling up amidst complexity

By Ann Larson

Ann Larson (biography)

How can new or under-utilized healthcare practices be expanded and institutionalized to achieve audacious and diverse global health outcomes, ranging from eliminating polio to reversing the rise in non-communicable diseases? How can complex adaptive systems with diverse components and actors interacting in multiple ways with each other and the external environment best be dealt with? What makes for an effective scale-up effort?

Four in-depth case studies of scale-up efforts were used to explore if there were different pathways to positively change a complex adaptive system. The analytical approach came from Axelrod and Cohen (1999) Harnessing Complexity. They noted that it was impossible to plan a response to every way a complex adaptive system might act, as there are too many possibilities. They recommended observing what surprises emerge as one intervenes; understanding the causes and effects of those surprises makes it easier to determine how to leverage, suppress or mitigate properties of a complex adaptive system to change its behaviour.

The case studies

Our retrospective case studies were of programs aiming to take high-impact health interventions to scale:

  • Case study 1 – postpartum IUD (intrauterine device) services in India;
  • Case study 2 – integrated community case management of childhood illnesses in Mali;
  • Case studies 3 & 4 – an approach to responding to newborns who have trouble breathing (Helping Babies Breathe) in Malawi and Bangladesh.

The studies drew on interviews with informants at the international, national, subnational, facility and community levels, as well as analysis of project documentation (Larson et al., 2015).

What the surprises revealed

We found scale-up efforts needed at least one of two factors to make a genuine contribution to institutionalizing and expanding a new healthcare practice:

  1. a responsive and adaptive scale-up team that gives hands-on support for change and/or;
  2. positive feedback loops internal to the complex adaptive system (especially by increasing community demand) that accelerate change.

These played out in different ways in the case studies.

Case Study 1

The Indian postpartum IUD scale-up effort relied on an intensely adaptive model designed to produce steady increases in capacity and coverage within the government health system. Jurisdictions and health facilities with low capacity received much more support than those with high capacity. There was an explicit plan to systematically extend the services by successively building capacity at each level.

Surprises involved changes in government policy regarding cash incentives to women adopters and providers for the method, early resistance by some clinicians and lack of confidence on the part of other clinicians. The scale-up team, led by respected clinicians, was able to identify and respond to the last two quickly. Eventually this scale-up project, which had received long term funding, would have to end. Informants said that sustaining the service was going to depend on building community demand. This was happening largely outside of the program, with other non-government organisations marketing postpartum IUDs and the government incorporating postpartum IUDs into its system of incentives.

Case study 2

The scale-up of the community-based child health program in Mali was not particularly adaptive. It involved recruiting and training community health workers to be placed in villages remote from primary health services. Its implementation was top-down and it was, to a large degree, imposed by donors.

Its surprises included a drought, civil unrest and diplomatic tensions as the project was being rolled out, conditions imposed by donors, and the complex interaction between the community associations that own the primary health care clinics and the government health system. But at the critical juncture when the case study was conducted, the real and perceived success had resulted in greater support in communities where capacity and resources were high and the program’s benefits clear.

Equally important, support had increased at the national level, largely because reductions in malaria deaths were attributed to the program. Some form of maintenance and expansion of the program was likely to continue, but with significant adaptations by the government, donors and the community health associations to make the program more sustainable and relevant.

Case studies 3 and 4

The Helping Babies Breathe scale-ups in Malawi and Bangladesh did not produce the desired changes in neonatal care, a surprise finding from evaluations conducted at the end of the project. The cascade training, lack of on-going monitoring and support and the particular challenges in creating community demand for a highly technical intervention were some of the reasons for failure.

However, the political will for addressing a common cause of neonatal mortality was established and in both countries there was interest in integrating the approach into a broader maternal and neonatal agenda. The initial Helping Babies Breathe scale-ups can be viewed as an initial sensitizing of the health care system, creating the conditions for local actors to adapt the intervention and accelerate change.


The findings from the in-depth case studies contribute to understanding how scale-up efforts directly and indirectly create system-wide change by becoming part of the complex adaptive system. The direct influence changes the norms and intrinsic incentives for health care practice through hands-on support by an adaptive scale-up team. Scale-up efforts also trigger positive feedback from community members and decision makers at all levels by changing their norms and expectations, but this process takes time as actors gradually adjust their norms.

An earlier review of 17 nation-wide projects to scale-up six maternal and child health interventions (Larson et al., 2014) – which had led to my interest in complex adaptive systems and scale-up – had found that only half had led to meaningful increases in coverage. Perhaps, in the life of a single effort, system-wide change is the exception rather than the rule. The most effective pathway is through a combination of direct support and the longer and less predictable path of providing opportunities for communities, organizations and actors within the health system to demand and shape the change they want.

What’s your experience been with donor-driven scale-up efforts? Have you found similar or different factors to be important?

The study was made possible through funding from the USAID flagship program on reproductive, maternal, newborn and child health. I acknowledge the important contributions of my co-authors Jim Ricca, Jessica Posner, Robert McPherson, and Anne LaFond, and of Eric Sarriot.

Axelrod, R. and Cohen, M. D. (1999). Harnessing Complexity: Organizational Implications of a Scientific Frontier. Free Press: New York, United States of America.

Larson, A., Ricca, J., Posner, J. and Raney, L. (2014). Lessons Learned from the Scale-Up Experience of Six High-Impact Interventions in Reproductive, Maternal, Newborn, and Child Health. USAID Maternal and Child Health Integrated Program (MCHIP): Washington DC, United States of America. Online:

Larson, A., McPherson, R., Posner, J., LaFond, A. and Ricca, J. (2015). Scaling Up High-Impact Health Interventions in Complex Adaptive Systems: Lessons from MCHIP, Jhpiego: Baltimore, Maryland, United States of America. Online: [In April 2023, the report was no longer available via this website, however it can be found at]. 

Biography: Ann Larson PhD is a demographer and public health researcher. She is a visiting fellow at National Centre for Epidemiology and Population Health, Research School of Population Health at The Australian National University in Canberra, Australia.

1 thought on “Scaling up amidst complexity”

  1. Such an insightful and interesting piece. I am struck by the emphasis given to the importance of contextual adaptation for successful scaling efforts: the evidence is building rapidly for this feature of scaling, raising huge challenges for a field that has been so convinced, for so long, that fidelity and control was the key to success. Companion blog here by Fixsen, Blase and Fixsen also reminds us that fidelity does matter however! So the big challenge must be: how do we anticipate the correct degree of latitude to allow, and how do we achieve that balance in the field? The discussion of surprises and emergence feels spot-on to me: and these examples also show that even ‘failure’ under the terms of the conventional metrics needn’t mean we’ve wasted our time or our money: it can build readiness and may be part of that slow process of shifting norms. A cheering thought! Great blog.


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