Trans-National Scale-Up of Services in Global Health

By Ilan Shahin, Raman Sohal, Will Mitchell, and Onil Bhattacharyya.

Scaling up health activities is increasingly recognized as necessary for translating initial commitments into broad access to health-related goods and services in low-and-middle income countries. There are many effective and inexpensive targeted health interventions that address the burden of disease in low and middle-income countries, but scaling to achieve population coverage is often limited due to weak infrastructure and distribution channels, regulatory challenges, and difficulties in finding skilled talent. Hence, while there is impressive innovation and commitment to implementing health services in low-and-middle income countries, scaling up remains a critical challenge and often an elusive objective. More and more attention is being devoted to understanding how innovative programs in low‐and-middle income countries can use market‐based approaches to deliver health care services to the poor at scale.

The study Trans-National Scale-Up of Services in Global Health was motivated by the need to answer two questions. What strategies do health services programs use to deliver health care services at scale in low-and-middle income countries? What are the characteristics of health services programs that target the poor and achieve multi-country scale? Using the Center for Health Market Innovation database, this study examines 116 programs that have achieved trans-national scale (TNS) across multiple disease areas and activity types, comparing them to 1,068 single-country programs. The study highlights commonly used approaches in health services delivery to achieve trans-national scale.

FIGURE 2: Distribution of health focus of trans-national scale (TNS) and single-country programs (SCP). doi:10.1371/journal.pone.0110465.g002Disease-specific focus: The study finds that trans-nationally scaled programs are more likely to focus on targeted health needs such as HIV/AIDS, TB, malaria, or family planning rather than provide more comprehensive general care. More than a third of the TNS programs offer HIV/AIDS services (37%), followed by family planning & reproductive health (22%) and maternal and child health (22%). This contrasts with single-country programs, where general primary care leads with 37% of responses (versus 16% in TNS).

FIGURE 2: Distribution of health focus of trans-national scale (TNS) and single-country programs (SCP).


Donor reliance: The data reveals that donor funding is the primary means of support for the majority of all programs, while being particularly important for programs that achieve trans-national scale. Funding among TNS programs is mostly donor-led, with 82% reporting donors as their primary funding source and 90% receiving at least some donor funding (i.e., only 10% received no donor funding). In contrast, 32% of single-country programs operate independently of donors.

Targeted care: The data demonstrate that more than half of the TNS programs target specific health needs such as malaria, TB, HIV/AIDs, and family planning. For instance, D-Tree International, which was founded in 2004, has expanded from Tanzania to Malawi, South Africa, and India, providing clinical protocols via decision support software on mobile phones for use by clinic staff and community health workers to help them assess, diagnose and treat patients. The protocols address a substantial range of targeted services (e.g. HIV/AIDS, family planning, maternal and child health, TB, malaria, and chronic diseases).

Supportive services versus clinical care: Among TNS programs, the most common approaches used included information technology (35%) and consumer outreach (34%), as well as multiple forms of delivery support (48%), including provider training, operational processes, equipment, and supply chain enhancement. Single-country programs were more likely to provide clinical care through standalone clinics or hospitals (10% v. none of the TNS programs) and/or health insurance (16% v. only 3% of TNS programs). Hence, trans-national scale programs tend to emphasize support services, while single-country programs are more likely than TNS programs to provide clinical care.

Insights from research

The characteristics of programs in the study that have achieved trans-national scale differ from single country programs for reasons that may reflect two drivers and barriers to scaling: funding and skills. First, while single country programs also commonly rely on donor funding, they are also more often able to draw on public financing and/or membership fees to support more comprehensive clinical care. Second, more comprehensive care requires deep and locally relevant clinical and management skills, which are often difficult to extend across national borders.

A few TNS programs, though, have achieved broader and deeper reach. These programs typically built on initial local success while also reaching out to gain support for provider training and operational support. Going forward, the challenge for more comprehensive programs that aspire to achieving transnational scale is to identify broader bases of funding and skills that can support such expansion.

Trans-national scale is important as it is a meaningful indicator of how broadly a program is able to spread its reach. Program managers and donors can benefit from knowing the characteristics of healthcare programs that achieve trans-national scale. The study suggests that certain processes can help advance TNS such as provider training, logistics support, and supply chain enhancements. The study also offers insights on the kinds of healthcare activities that are more amenable to scale up. Most generally, this study is part of global efforts to understand how scale is achieved in practice, with the goal of helping health services scale effectively to improve population health.


Photo: © D-Tree International