The pitfalls of scaling up evidence-based interventions in health

ABSTRACT

Policy-makers worldwide are increasingly interested in scaling up evidence-based interventions (EBIs) to larger populations, and implementation scientists are developing frameworks and methodologies for achieving this. But scaling-up does not always produce the desired results. Why not? We aimed to enhance awareness of the various pitfalls to be anticipated when planning scale-up. In lower- and middle-income countries (LMICs), the scale-up of health programs to prevent or respond to outbreaks of communicable diseases has been occurring for many decades. In high-income countries, there is new interest in the scaling up of interventions that address communicable and non-communicable diseases alike. We scanned the literature worldwide on problems encountered when implementing scale-up plans revealed a number of potential pitfalls that we discuss in this paper. We identified and discussed the following six major pitfalls of scaling-up EBIs: 1) the cost-effectiveness estimation pitfall, i.e. accurate cost-effectiveness estimates about real-world implementation are almost impossible, making predictions of economies of scale unreliable; 2) the health inequities pitfall, i.e. some people will necessarily be left out and therefore not benefit from the scaled-up EBIs; 3) the scaled-up harm pitfall, i.e. the harms as well as the benefits may be amplified by the scaling-up; 4) the ethical pitfall, i.e. informed consent may be a challenge on a grander scale; 5) the top-down pitfall, i.e. the needs, preferences and culture of end-users may be forgotten when scale-up is directed from above; and 6) the contextual pitfall, i.e. it may not be possible to adapt the EBIs to every context. If its pitfalls are addressed head on, scaling-up may be a powerful process for translating research data into practical improvements in healthcare in both LMICs and high-income countries, ensuring that more people benefit from EBIs.

KEYWORDS:

• Scaling-up
• evidence-based intervention
• harms
• equity
• cost-effectiveness
• ethics
• health

Responsible Editor Stig Wall, Umeå University, Sweden

Responsible Editor Stig Wall, Umeå University, Sweden

Acknowledgments

We thank Roxane Lepine, scientific librarian, for assistance in our literature search; and Louisa Blair, English-language scientific editor, for her kind help with the manuscript.

Author contributions

HTVZ, ABC and FL initiated the project. All authors contributed to the draft, and approved the final version of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

Not applicable.

Paper context

This current debate paper is written in a context in which policy-makers worldwide are increasingly interested in scaling up evidence-based interventions (EBIs) to larger populations. Although the scaling-up of EBIs has the great potential to reduce the gap between EBIs and practices, major pitfalls need to be anticipated. This paper discusses these pitfalls to permit to investigators to better plan their scaling-up of EBIs.

Additional information

Funding

This work was funded by the Quebec SPOR-SUPPORT Unit [#SU1-139759] and the Canada Research Chair in Shared Decision Making and Knowledge Translation [#950-231200]. The Quebec SPOR-SUPPORT Unit is funded by the Canadian Institutes of Health Research (CIHR) and provincial partners including the Ministère de la Santé et des Services Sociaux (MSSS) du Québec and the Fonds de recherche du Québec – Santé (FRQ-S). The Canada Research Chair is also supported by the CIHR. Only the authors are responsible for the information provided or views expressed in this paper.