A Guide for Fostering Change to Scale Up Effective Health Services

This Guide, produced for the Implementing Best Practices (IBP) Consortium by the Leadership, Management, and Sustainability (LMS) Project of Management Sciences for Health (MSH), is intended for use in bringing change in performance and quality of services to reproductive health (RH) programmes. The Implementing Best Practices (IBP) Initiative is a global partnership involving 26 international agencies dedicated to demonstrating a dynamic model of international and local cooperation on RH.


The primary audience for the guide includes change coordination teams, health service managers in charge of change, co-workers comprising a change team; and implanters of change in daily work environments. Levels of change include clinical practices, health provider behaviours and practices, management practices, and management systems. The guide offers the principles and "how-to" of fostering change, supported by examples. It is accompanied by a CD-ROM that includes an MS Word PowerPoint presentation and selected tools for implementation.


Principles include the following:

1. "Change must matter to those making the change.... 'The greater the perceived advantage, the more rapid the adoption.' ....Influential characteristics of an innovation are relative advantage; compatibility; simplicity; trialability; and observability.
2. A credible, committed internal change agent inside the system to be changed is critical for change in health care practices.
3. [External] support from those who can share knowledge with the internal change agent gives the agent the credibility and confidence to lead.
4. Change is more likely to succeed when leadership at each organisational level supports it and when it is introduced into an environment where change is an ongoing practice.
5. Clarity is needed about the purpose, benefits, and anticipated results of the change.
6. Motivating and supporting staff throughout the change process will help to maintain their dedication and create a support network for the change agent.
7. Clearly assigned and accepted responsibility for implementing the change increases the chances of sustaining the change as a part of ongoing work.
8. Start where you can and start now."




The guide summarises the steps to effect change and then illustrates them with step-by-step case studies. The phases, in summary, are the following:



• "Preliminary Phase: Forming the Change Coordination Team
• Phase I: Defining the Need For Change
  a. Identify the problem - a practice or set of practices that is impeding the provision of high quality services - analyse the root causes, and reformulate the problem as a challenge.
  b. Identify and agree on the desired change, its purpose, the anticipated results, and the potential obstacles. (Why are we doing this? How will the services benefit from doing it? What may make it hard to achieve?)
• Phase II: Planning for Demonstration and Scale-Up
  a. Select a dedicated change agent (if one has not already been appointed) and a change team.
  b. With the change agent, identify and analyse relevant effective practices from other settings.
  c. Choose and adapt an effective practice that is appropriate for the service delivery context and the needed change.
  d. With the change agent and change team, make a plan to implement and monitor the demonstration of the desired change at test sites.
  e. Building on the implementation plan, make strategic choices for scaling up a successful change effort.
• Phase III: Supporting the Demonstration
  a. Help to create and maintain an environment that will encourage change by supporting the change agent, change team, and other staff throughout the change process at the test sites.
  b. Use the change plan and indicators to continually assess, monitor, and modify the change effort."
• Phase 4: Going to Scale with Successful Change Efforts
  a. Evaluate, coordinate and disseminate lessons learned from the demonstration, and decide whether or not to scale up the new practice or set of practices.
  b. If the demonstration succeeded, select a scale up strategy that best suits the country or regional program environment.
  c. Engage the commitment of a broad group of stakeholders and secure resources to support the selected scale up strategy.
  d. Implement the scale up strategy, incorporating the new practice or set of practices into existing policies, systems, programs, plans, budgets, and performance expectations.
  e. Measure and communicate the results of the scaled up practices.