All inventors are faced with the same dilemma at some point. When you have proved that a new innovation works, what do you do next: come up with something new, tweak your product endlessly in a search for perfection, or attempt to get it up and running in as many places as possible? In this respect, prevention science is no different and those who have proved a new intervention or programme works confront these same questions.
Since the road from the drawing board to a recognisable, proven product is a long one, it is unsurprising that few in the prevention science world have successfully got their programmes into mainstream usage. But with over 20 years of innovating, testing and implementing in the field, taking the product to scale - that is, expanding it to new places and people - has to be the next mountain to climb.
Some are further along the road than others. The Family Nurse Partnership, an intensive home visiting programme for young, vulnerable first time mothers, and Multi-Systemic Therapy, an intensive therapeutic intervention for anti-social young people, are two prevention programmes whose utility has been proven and that could claim that they are operating at scale. They are serving thousands of families in most US states and operating in other countries. But is this what we mean by “scale”, and what level of recognition, spread and take-up constitutes success?
Although not all of the answers lie in the business world, no one can dispute that their technologies for expansion are impressive. Just think of the reach – both geographic and in terms of number of customers – achieved by the likes of McDonald’s and Coca-Cola. These companies replicate their products across multiple outlets reaching millions, attending assiduously to keeping quality variation to a minimum, while at the same time adjusting their product to the local environment. In the world of evidence-based programmes and practices, there isn't yet a McDonald's equivalent.
These themes are touched on by a report from the Harvard Family Research Project, which suggests the six steps required for a non-profit organisation thinking of taking its interventions to scale.
They take as a given that the first step is to determine whether the intervention is ready to go to scale. A number of questions need to be addressed. Is there a clear statement of why and how the programme works? Has the impact of the programme been proven and has this impact been replicated in different places? Does the programme continue to work even in the context of local variation? And, crucially, is there sufficient investment, both financial and non-financial, for the quality of the intervention to be maintained once it is being used in a number of different places?
There are certainly parallels here with the business sector. Although the case of McDonald’s was probably different – the company would have needed to prove that their business had the potential to be profitable in single and multiple outlets to get investors - they would still need to have considered how to ensure a Big Mac looks and tastes the same whoever is cooking it and wherever they are.
If the programme is ready to expand, then the next step is to decide on an approach. One option is to look at reaching more of those the intervention is designed to help from the places it is already operating in; another is to replicate the programme in multiple new sites. Increasing the number of people being reached by the programme, financial capacity (both capital and cash flow) and sustainability all need to be considered at this point.
Just as a supermarket chain will consider numerous characteristics to ensure that a new site for a store has a strong chance of meeting local needs and being profitable, so too will plans to take a programme to scale. Assessing the readiness of a new site includes looking at characteristics like the quality and training of staff, organisational commitment and the needs of those being targeted by the intervention.
Once the decision has been taken to attempt to get a programme up and running in multiple places, an infrastructure and procedures need to be put in place to ensure that it is efficiently and effectively managed. This fourth step will include a system for monitoring and maintaining quality, methods for communicating between the centre and the sites, and data collection on implementation and impact. Just as a supermarket will collect rafts of data on sales, the impact of promotional activity, and customers’ buying preferences, so programmes will also benefit from timely data systems to spot, and rapidly respond to, potential problems.
Evaluation is offered as the fifth step. For example, the factors that have impeded efforts to expand the programme and the extent to which the programme’s impact is maintained across a variety of places will be critical to future attempts to take it to further places.
The final step is a recommendation to develop theories and practices for expansion which can then be shared across the non-profit sector, since it is a relatively new area for most organisations. This is, of course, one area where the analogy with the business sector does not hold. They are more likely to copy successful practices than altruistically share their ideas!
Where perhaps the analogy does still work is in the area of supply and demand. Profit-making companies not only look to meet demand by providing products and services that customers want, they also stimulate demand through advertising, marketing and other activities, and demonstrating how their products can meet the customer’s needs.
It is in this respect that prevention science appears to have much to learn. The providers of programmes need to demonstrate how their programmes can fit the public sector landscape and how improving outcomes for children fits with their agency responsibilities.
Coca-Cola and McDonald's may not be the most obvious comparisons for many of those working to expand programmes in prevention science, but understanding the lessons of their success when it comes to scale is probably not a bad place to start.
Harris, E. (2010) 'Six Steps to Successfully Scale Impact in the Public Sector', The Evaluation Exchange, Vol XV No 1 - link to the articleReturn to Features