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Family Health "Check Up" 2013: Lessons Learned

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May 17, 2013

This is the fifth post in the six-part Family Health "Check Up" 2103 series which provides a window into the ways in which we think about our Family Health strategy, at the foundation. Follow @gatesfoundation and @gdarmsta on Twitter to join the conversation. 

As we prepare for our annual strategy reviews in Family Health, we took time to reflect on what we’ve learned over the past year.  One overarching lesson jumped out at us: if our goal is truly to achieve impact at scale, then we must be more purposive in our approaches to learning and knowledge sharing. Intentionality in learning requires that we identify lessons from our current investments, apply them to inform both future grant-making and short-term course correction in existing programs, and utilize them to improve our engagement model to sustain performance gains across all our investments and partnerships.

But collecting lessons is not enough.

We have also come to understand that it’s imperative to become better at sharing knowledge across foundation teams as well as among our partners. Learning from our partners and helping connect this collective learning to our global practice in Family Health are critical efforts to increasing the efficiency and effectiveness of our joint efforts. This in turn is pivotal to achieving “solution leverage” or, in other words, ensuring that the global Family Health effort reaches lasting impact at scale in the geographies were we invest directly, and that solutions spread and have further impact beyond those geographies.

  Learning from our partners and helping connect this collective learning to our global practice in Family Health are critical efforts to increasing the efficiency and effectiveness of our joint efforts.

Through this process of reflection, we identified a few “success factors” for achieving impact at scale that we want to share.

  • Understanding partners’ capacities and capabilities and the broader systems in which they operate are critical upfront analyses. Most of our investments are made in complex environments. Understanding the different elements comprising such environments, and their interdependence, can help us identify leverage points within the system that could bring-about catalytic improvements in health, anticipate and mitigate risks and unintended negative consequences of actions within the system, and adjust implementation to capitalize on learning and reduce loss-of-value from factors like these. Salud Mesoamerica 2015 (SM2015) is a multi-country public-private partnership that employs an outcomes-based funding approach to leverage recipient government domestic funding and policy efforts to improve health status of the poorest women and children throughout this region. During project design detailed partner landscaping led to the selection of an “anchor partner” (the Inter-American Development Bank, IADB) that had demonstrated capabilities to engage with governments, and a wide array of partners and sub-grantees in Mesoamerica. Such a choice led to a thorough understanding of institutional contexts, health system bottlenecks, and the determinants of demand for health among households and communities. The IADB and participating countries jointly identified optimal approaches to address existing constraints and opportunities by creating and fostering regular opportunities to engage in policy dialogue. This has since resulted in strong governmental support exemplified by valuable upfront political and financial commitments which, in turn, are conducive to the production of health improvements among program beneficiaries.
  • Designating a lead partner can increase our solution leverage, compelling us to very clearly define expectations and goals upfront to enable stronger, more focused implementation downstream. The Alive & Thrive project, as a consortium of NGO, private sector and academic partners from around the world, focuses efforts on defining, testing, and learning from innovative models for achieving improved nutrition at scale, focusing on promotion of breastfeeding and complementary feeding. FHI360, as the lead NGO for this project, has promoted a common vision among partners and has streamlined project management. Another successful factor of this project has been embedding an evaluation partner within the consortia, enabling a robust evaluation design and insisting that the implementation partners articulate clearly their assumptions and delivery plan at the outset of the project.
  • Large scale implementation projects need to be planned with the end in sight. Both Alive & Thrive and Salud Mesoamerica 2015 were designed for impact at scale, with the expectation that the public-private franchise- and media-based models of Alive & Thrive and the government-led outcomes-based financing approach in Salud Mesoamerica 2015 will enable the scale-up of health outcomes and not solely the replication of specific solutions or interventions.  Both programs take known, efficacious health interventions, understand what it will take for them to be adopted in different contexts and within different populations, and accompany implementing partners as they deploy and adapt them to their local contexts, and in this iterative process of learning, turn them into routine practices. Along this value chain, innovative solutions become routine practices which, in turn, lead to effective coverage and, eventually, to the end we have in sight: improved maternal and young child health and survival.
  • The monitoring, learning and evaluation portion of a project should inform the design of the intervention and provide timely, on-going monitoring data to enable continuous adjustment and improvement in performance. One example of this is seen with the Ananya project, a portfolio of integrated investments that tests a series of family health solutions in eight districts in Bihar, India, in partnership with the state government. Part of the project plan includes scale up of a subset of the most effective solutions to the remaining 30 districts of Bihar over the next two years. Through a collaborative approach with more than 10 partners, the extensive measurement in this project, including regular monitoring of inputs and changes in knowledge and practices can lead to more information to know when and how to course correct to continually improve program performance and evidence for impact of innovations.
  • Building early and ongoing alignment with government is critical for sustainability, as governments typically inherit the continuation of interventions. One example of engagement of relevant government bodies is GAIN’s work in Uganda. Through early and ongoing engagement coupled with initial scale-up and demonstration of the cost-effectiveness of interventions in addressing micronutrient deficiencies, Uganda now has policies and legislation that mandates fortification and supports the longer-term sustainability of staple food fortification. The government has recently allocated resources through the national budget to sustain implementation.
  • Changing family health behaviors is critical for impact, and requires alignment of messages and actions across a variety of communication channels and addressing multiple demand- and supply constraints simultaneously. We draw this lesson from across all of our projects. It’s a major tenet in our end-to-end approach to product development and spread, it is instrumental for the work of frontline health workers, and it has broadened our engagement model for newborn health. Sustained improvements cannot be achieved through the health system alone. Ultimately all women need a supportive home, community, and work environment to support adherence to healthy behaviors.

While these success factors come from different developing country contexts, they each contain common themes that can help identify emergent practices that, if properly used, can lead to projects that are better designed to achieve measurable results and to implement plans that are responsive to dynamic implementation contexts.

And by doing so, we can achieve lasting impact at scale.

Do these lessons ring true for you? How are these applicable in your own work? What key things are you learning about achieving and sustaining impact at scale?

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