Why scaling up fails

Scaling up a successful small-scale program involves changes to the program. In some cases, that includes a shift in providers, from individuals employed by a private agency to civil servants. This could have both a quality effect (moving from specialists to generalist civil servants) and a motivation effect — both intrinsic, since specialist agencies might employ people who care more, and extrinsic, since non-government agencies might find it easier to fire people.

Lisa Cameron and Manisha Shah have a new paper that examines the scale-up of a sanitation program in Indonesia. From the abstract:

This paper evaluates the effectiveness of a widely used sanitation intervention, Community-Led Total Sanitation (CLTS), using a randomized controlled trial. The intervention was implemented at scale across rural East Java in Indonesia. CLTS increases toilet construction, reduces roundworm infestations, and decreases community tolerance of open defecation… We also examine the program’s scale up process which included local governments taking over implementation of CLTS from professional resource agencies. The results suggest that all of the sanitation and health benefits accrue from villages where resource agencies implemented the program, while local government implementation produced no discernible benefits. [emphasis added]

Okay, so when the government took over, the program didn’t work. Why? They explore a number of mechanisms. The data suggest that the problem is NOT the quality of the facilitators: 

In the field one hears a lot about the importance of the “quality” of the facilitator. In order to test whether the RA facilitators are “better” than the LG facilitators, we collected information from respondents on their perceptions of how charismatic/persuasive the facil- itators were… There is no significant difference in the average reported persuasiveness of the facilitators.

What else?

The intensity of implementation is…greater in RA villages (driven by facilitators making more visits).

More people had heard about the program in RA villages, and “RAs appear to be more effective at reducing tolerance to open defamation.”
This points to motivation rather than quality, in this particular case.

The paper reminds me of Kerwin & Thornton’s work on teacher training in Uganda, in which a “full” version of the program had large impacts on student learning, whereas a lower cost version used government employees (whose job is to train teachers) as well as fewer materials: 

A cost-effectiveness comparison of the two programs reveals the low-cost version to be slightly more cost-effective than the full-cost one… However, focusing on the “headline” measure of letter name knowledge hides significant drawbacks to the low-cost version of the program: the cost-effectiveness result is reversed when considering the overall reading score index, and the low-cost version of the program causes a small (but statistically-insignificant) decline in students’ English speaking ability… Most concerningly, the low-cost program causes large and statistically-significant reductions in several aspects of writing ability – of about 0.3 SDs – relative to the control group. In contrast, the full-cost version of the program improves writing scores across the board, with the effects on several exam components being statistically significant.

In that case, reduced inputs may also play a role. But it is potentially additional evidence that a shift in implementer can have a major impact. 

Bold et al. find something related when examining the scale-up of a contract teacher intervention in Kenya: 

What constraints arise when translating successful NGO programs to improve public services in developing countries into government policy? We report on a randomized trial embedded within a nationwide reform to teacher hiring in Kenyan government primary schools. New teachers offered a fixed-term contract by an international NGO significantly raised student test scores, while teachers offered identical contracts by the Kenyan government produced zero impact. Observable differences in teacher charac- teristics explain little of this gap. Instead, data suggests that bureaucratic and political opposition to the contract reform led to implementation delays and a differential interpretation of identical contract terms.
[emphasis added]

Last week, on the World Bank’s Development Impact blog, I wrote about an experience with scaling up an education pilot in Kenya where the pilot was explicitly implemented using existing government programs, where government actors are playing roles already included in their job descriptions. The pilot was effective, and results on the scale up come in later this year. Fingers crossed.


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