Implementing, Maintaining, Scaling Up and Sustaining (IMSS) Approaches, Programs and interventions

Planning for the implementation, maintenance, scale up, sustainability of these multi-intervention approaches and programs requires use of traditional, effective, operational planning steps such as involving stakeholders, selecting effective programs and using evidence-based and experience-tested implementation models and frameworks. Planners should also identify local barriers/drivers of change such as inter-organizational relationships, recent events and incidents. Planning should include considerations of scaling up, start-up and ongoing costs, succession of key personnel and sustainability from the start. A thorough understanding of the local situation, magnitude, complexity and the “fit” or congruence a between the planned interventions or approach with the local situation, the use of evidence-based and experience-tested planning tools and clarity about the intended outputs from different distribution, dissemination or diffusion (institutionalization) strategies are also required.

The FRESH Partners have agreed that IMSS concepts and strategies should be better described within the FRESH Framework. The FRESH Coordinating Committee reviewed a summary of what is known about IMSS and decided that this knowledge should be included in the revised set of FRESH Cross-Cutting Themes and within the revised  FRESH Thematic Indicators, beginning with the topic of substance abuse prevention. Visit those pages to see how IMSS knowledge has developed over recent years. Here is a list 0f the strategies suggested in that paper: More detailed advice and relevant research & resources are included in the FRESH discussion paper.

1. Begin with the end in mind. Start by considering the end-product in realistic and costed terms, identifying changes in the systems/organizations, people that need to be convinced, how a critical mass supporting change will be achieved and other similar aspects of sustainability will be maintained.
2. Be clear about your intended process and required resources. The outputs possible from simply distributing a guidance document,disseminating a resource accompanied by technical advice and encouragement, and diffusing an innovation with defined funding, staffing and training vary considerably. Ensure that your expectations for lasting change are commiserate with the process selected and the resources provided.
3. Consider the size, time and costs of the intended innovation or change to determine the time needed for implementation: A low-cost policy change such as regulating food sales in schools will likely take a year to develop with stakeholders and then 2-3 years to implement in a school system. A large cost intervention such as school meals can take 10-15 years to implement in a national system if the maintenance stage is to include local government funding (as opposed to external) funding and the provision of local grown foods. Aligning multi-interventions within a multi-component approach such as Health Promoting Schools will take even longer. Start-up and ongoing costs of the intended policy, program or approach should be estimated and planned for in advance. Individual schools are open and adaptive to small scale, low cost “innovations” but education agencies and ministries are often resistant to large scale reforms that require them to change the balance among their custodial,  academic, vocational, socialization and certification/selection functions. Other systems are similar.
4. Assess the scope, complexity, fit/, ransferability of the intended innovation or change: The fit or transferability of an innovation or change can be measured and placed on a scale.
5. Use key, traditionally identified implementation mechanisms:  These mechanisms are often described in various guides and manuals. These include involving stakeholders from the outset, selecting evidence-based and experience-tested programs, building staff and organizational competencies and other actions.
6. Use evidence-based and experience-tested implementation models & frameworks such as Re-AIM, Concerns-based Adoption, PRECEDE-PROCEED or the Consolidated Framework for Implementation Research.
7. Identify local barriers/drivers of change: Anticipate the possible interactions between the intended innovation/change, the local context[iii],[iv],[v] and the processes that you intend to follow. These include such elements and aspects such as attributes of the local community, inter-organizational relationships, recent events and incidents, cultural fac tors, personal relationships among key individuals, the history and evolution of the problem and related programs in the country and more.
   
8. Work through some of the challenges and ambiguities related to scaling up Overcoming challenges associated with “scaling up” approaches, policies and programs[i] is best done through iterative and incremental strategies. Lessons learned from successful scaling up activities[i] include; using local evidence and experience, building institutional capacity, providing ongoing technical support when scale up involves complex interventions, integrating considerations of gender and equity issues into the process and ensuring ongoing feedback and formative assessments. Clarity in defining the scalable unit within the organization is critical – for too long in school health & development, the individual school has been treated as that unit for change but in reality, it must include the ministries and local authorities and agencies.
   
9. Think clearly and realistically about the sustainability of comprehensive approaches: Planning for sustainability is the first stage of a process that must engage all relevant stakeholders from the outset, not in the middle or at the end of a pilot project. Sustainability must be achieved at multiple levels (professionals, school, school board/health authority/agency and ministries) within several systems to be stable.
   
10. Recognize critical events, junctures, plateaus or transition points in the scaling up or scaling down of the comprehensive approach:Often these critical events, junctures or transitions can become bottlenecks, barriers, plateaus or breaking points that prevent the full development of a coherent and comprehensive approach. One type of transition or critical event occurs in all multi-intervention approaches. The transition occurs when isolated, individual interventions become a more effective, coordinated set of policies and programs that make up a multi-faceted approach.