Twenty-three studies met inclusion criteria for this scoping review. Most studies analyzed OH initiatives that addressed human health, animal health or environmental health.

The IHI Framework for Spread highlighted the importance of understanding determinants of change and the system environment for implementing changes at scale. This is a necessary step in addressing the challenges of taking an initiative to full scale.
What is a Large-Scale Health Initiative?

Attempting to address the world’s most pressing health issues requires a broad array of interdependent partnerships across sectors and disciplines. Such efforts include coordinating care across the continuum of health and human services, developing integrated approaches to prevention and treatment of complex chronic conditions such as cardiovascular disease and diabetes, and aligning policies, incentives and financing strategies to incentivize collaboration in service delivery.

Taking these kinds of initiatives to scale can be challenging, but there are ways to make them more effective and efficient. A number of frameworks have been developed to guide these kinds of reforms, and many of them take into account the need for a holistic approach that takes into account factors at the smallest scale (e.g., details of the intervention) as well as the larger socio-political context and economics (e.g., the global economy) [3]. 大規模修繕 

In terms of specific implementation approaches, the most promising appear to be ones that incorporate a realist methodology and draw lessons from fields beyond health care. These involve analysing a range of realist findings from individual case studies of large-system initiatives'vertically' to identify common thematic elements according to context, mechanism and outcomes, and then 'horizontally' across a set of cases to uncover potentially generative causal patterns or regularities across different initiatives, contexts, mechanisms and outcomes to support generalisation.

This kind of analysis can help identify gaps in knowledge and understanding of the specific challenges to achieving success at scale, and can also help guide the development of new models that are designed to meet those challenges more effectively. One example is the 3.0 Transformation Framework, which emphasizes the role of activated patients who become designers and co-producers of their own lifelong health development; of engaged communities that are focused on creating local conditions that support such development; and of motivated populations that work to engage with and participate in a system of care that delivers value for money over time.

In addition, the Framework recognizes that funding strategies are crucial to successful scaling. These need to align incentives for collaboration between providers and consumers, promote innovative partnerships that span health and social service sectors, and use novel methods for sharing accountability across organizations. These could include innovative payment systems like multisector risk-based contracting or health trusts that pool resources to incentivize joint responsibility for delivering health and well-being.
Why are Large-Scale Health Initiatives Important?

In a world where the burden of disease and death is disproportionately high in developing countries, it is important to focus efforts on large-scale health initiatives. These initiatives have the potential to improve health care delivery, increase access to lifesaving treatments, and help build healthier communities. However, they are not without their challenges. Large-scale projects must be able to navigate the many barriers to effective implementation and scale.

These obstacles include a lack of resources, limited capacity for training, resistance from recalcitrant stakeholders, and the difficulty of adapting and applying best practices in new settings. In addition, successful large-scale initiatives need to ensure the sustainability of their work. This is especially critical in the face of the ever-increasing global population, which will lead to increased demand for health services.

To overcome these challenges, many large-scale health initiatives implement a framework for scaling up an intervention. This framework consists of three core components: setting up an enabling environment; preparing for scale-up with structured improvement methods; and progressing to full scale. While a number of existing frameworks for scaling up an intervention address each component to different degrees, few provide actionable guidance on how to combine them into a coherent plan for scaling up.

The Institute for Healthcare Improvement (IHI) has learned from its direct involvement in large-scale health initiatives around the globe that a comprehensive approach is essential. The white paper IHI developed, titled “Preparing for Scale,” provides an overview of the complexities associated with large-scale improvements and outlines key questions that should be considered by a core group of stakeholders in the months leading up to an initiative.

IHI has partnered with several nations to introduce large-scale, intersectoral, and community-based improvement initiatives. These projects are designed to take promising practices that have proven effectiveness in one context or isolated environment and make them ubiquitous across a region, state, or nation. Examples of such initiatives include the 100,000 Lives Campaign and the Institute’s Global Patient Safety Initiative.

Unlike traditional healthcare improvement projects, these broader initiatives seek to break down silos between human health, animal health, and environment health and address the many factors that impact health outcomes. As the global health community continues to work towards sustainable development goals, broader intersectoral collaborations like these will become increasingly necessary.
How Can Large-Scale Health Initiatives Be Successful?

Taking effective interventions from local to broader settings can be challenging. The success of these efforts depends on a number of factors, including the ability to engage and influence key stakeholders, the quality of the initiative itself, and the presence or absence of critical barriers and impediments. These challenges can be overcome with careful planning, thoughtful evaluation, and attention to the context in which the effort is being implemented.

This IHI white paper describes how to identify these factors and implement the necessary steps for successful large-scale improvement initiatives. It includes an overview of the challenges and opportunities that come with improving health care at a large scale, as well as an exploration of some key lessons learned from previous large-scale improvements efforts. It also provides guidance for identifying the right scalable unit and a process for assessing whether it is ready to move to a full-scale improvement effort.

The 23 eligible studies included a mix of human and animal health (OH) initiatives, targeting different infectious diseases or antimicrobial resistance (AMR). Most were focused on the field of zoonotic disease prevention and control. Rabies was the most commonly targeted disease, followed by vector-borne diseases such as dengue, Chagas disease, faecal worms (including hookworms and whipworms) and soil-transmitted helminths (such as giardiasis). Other targets were bacterial diseases including brucellosis and campylobacteriosis and non-vector borne parasitic infections such as schistosomiasis and opisthorchiasis.

Studies used a variety of methods for evaluation, with most using at least one quantitative approach. Qualitative data were also collected in many of the evaluations. Normative and evaluative approaches were used in four and 20 studies respectively, with evaluative research generally involving impact analyses. Normative evaluations seek to compare the initiatives’ structures, processes and outcomes against defined standards or criteria.

Although there are a number of existing frameworks for scaling up, none explicitly address the core components of how to take an intervention from pilot to full scale: 1) establishing a purposeful plan to scale-up; 2) establishing a scalable unit; and 3) designing a sequence of spread and growth strategies. Several of the existing frameworks do address some or all of these components, but not in an integrated way that can be readily applied to a new health initiative.
What Can Large-Scale Health Initiatives Learn from Each Other?

As health professionals around the world seek to improve global health outcomes, they must take a multifaceted approach that includes addressing both environmental and social determinants of health. Ultimately, the success of such efforts depends on the engagement and commitment of community members. This is especially true for communities in remote or marginalized areas, where a lack of accessibility to resources and services can lead to high infant mortality rates, malnutrition and poor quality of life.

Health professionals can empower community partners by involving them in the process of developing and implementing interventions. This is an important way to increase community buy-in and bolster the sustainability of an initiative. It can also help to identify new avenues for reaching individuals that may not have been previously accessible. For example, some communities may be more receptive to information and education about zoonotic diseases and antimicrobial resistance (AMR) from barbers or beauty salons than traditional healthcare providers.

One of the most critical challenges for large-scale health initiatives is ensuring that they are implemented at scale with a minimum of disruption to existing operations. To do this, health leaders must ensure that scalable units are identified, tested, and refined before moving to larger systems or areas of care.

In the case of OH initiatives, this could include a hospital or district level, or an Accountable Care Organization. To accelerate the testing and build initial change packages, health leaders can apply the IHI Breakthrough Series Collaborative model to create a “test of scale” at a small site or region (e.g., a district or clinic). This allows for quick feedback and learning from the initial implementation and avoids unintended consequences that might be caused by jumping straight to full scale.

Similarly, if an intervention needs to be implemented across multiple regions or countries, a system for defining scalable units and linking them together has to be developed. This can be done using a “microsystem” definition, which involves identifying a work area or department with shared clinical and business aims, linked processes, a common information environment and performance outcomes.