"It’s About the Idea Hitting the Bull’s Eye": How Aid Effectiveness Can Catalyse the Scale-up of Health Innovations

Background: Since the global economic crisis, a harsher economic climate and global commitments to address the problems of global health and poverty have led to increased donor interest to fund effective health innovations that offer value for money. Simultaneously, further aid effectiveness is being sought through encouraging governments in low- and middle-income countries (LMICs) to strengthen their capacity to be self-supporting, rather than donor reliant. In practice, this often means donors fund pilot innovations for three to five years to demonstrate effectiveness and then advocate to the national government to adopt them for scale-up within country-wide health systems. We aim to connect the literature on scaling-up health innovations in LMICs with six key principles of aid effectiveness: country ownership; alignment; harmonisation; transparency and accountability; predictability; and civil society engagement and participation, based on our analysis of interviewees’ accounts of scale-up in such settings. Methods: We analysed 150 semi-structured qualitative interviews, to explore the factors catalysing and inhibiting the scale-up of maternal and newborn health (MNH) innovations in Ethiopia, northeast Nigeria and the State of Uttar Pradesh, India and identified links with the aid effectiveness principles. Our interviewees were purposively selected for their knowledge of scale-up in these settings, and represented a range of constituencies. We conducted a systematic analysis of the expanded field notes, using a framework approach to code a priori themes and identify emerging themes in NVivo 10. Results: Our analysis revealed that actions by donors, implementers and recipient governments to promote the scale-up of innovations strongly reflected many of the aid effectiveness principles embraced by well-known international agreements - including the Paris Declaration of Aid Effectiveness. Our findings show variations in the extent to which these six principles have been adopted in what are three diverse geographical settings, raising important implications for scaling health innovations in low- and middle-income countries. Conclusion: Our findings suggest that if donors, implementers and recipient governments were better able to put these principles into practice, the prospects for scaling externally funded health innovations as part of country health policies and programmes would be enhanced.

I n a recent contribution to the ongoing debate about the role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics. He identifies three related problems: (1) a lack of agreement among global health scholars about their normative premises, (2) a lack of agreement between global health scholars and policy-makers regarding the normative premises underlying policy, and (3) a lack of willingness among scholars to clearly state their normative premises and assumptions. This confusion is for Ooms one of the explanations "why global health's policy-makers are not implementing the knowledge generated by global health's empirical scholars. " He calls for greater unity between scholars and between scholars and policy-makers, concerning the underlying normative premises and greater openness when it comes to advocacy. 1 We commend the effort to reinstate power and politics in global health and agree that "a purely empirical evidence-based approach is a fiction, " and that such a view risks covering up "the role of politics and power. " But by contrasting this fiction with global health research "driven by crises, hot issues, and the concerns of organized interest groups, " as a "path we are trying to move away from, " Ooms is submitting to a liberal conception of politics he implicitly criticizes the outcomes of. 1 A liberal view of politics evades the constituting role of conflicts and reduces it to either a rationalistic, economic calculation, or an individual question of moral norms. This is echoed in Ooms when he states that "it is not possible to discuss the politics of global health without discussing the normative premises behind the politics. " 1 But what if we take the political as the primary level and the normative as secondary, or derived from the political? That is what we will try to do here, by introducing an alternative conceptualization of the political and hence free us from the "false dilemma" Ooms also wants to escape. "Although constructivists have emphasized how underlying normative structures constitute actors' identities and interests, they have rarely treated these normative structures themselves as defined and infused by power, or emphasized how constitutive effects also are expressions of power. " 2 This is the starting point for the political theorist Chantal Mouffe, and her response is to develop an ontological conception of the political, where "the political belongs to our ontological condition. " 3 According to Mouffe, society is instituted through conflict. " [B]y 'the political' I mean the dimension of antagonism which I take to be constitutive of human societies, while by 'politics' I mean the set of practices and institutions through which an order is created, organizing human coexistence in the context of conflictuality provided by the political. " 3 An issue or a topic needs to be contested to become political, and such a contestation concerns public action and creates a 'we' and 'they' form of collective identification. But the fixation of social relations is partial and precarious, since antagonism is an ever present possibility. To politicize an issue and be able to mobilize support, one needs to represent the world in a conflictual manner "with opposed camps with which people can identify. " 3 Ooms uses the case of "increasing international aid spending on AIDS treatment" to illustrate his point. 1 He frames the I n a recent contribution to the ongoing debate about the role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics. He identifies three related problems: (1) a lack of agreement among global health scholars about their normative premises, (2) a lack of agreement between global health scholars and policy-makers regarding the normative premises underlying policy, and (3) a lack of willingness among scholars to clearly state their normative premises and assumptions. This confusion is for Ooms one of the explanations "why global health's policy-makers are not implementing the knowledge generated by global health's empirical scholars. " He calls for greater unity between scholars and between scholars and policy-makers, concerning the underlying normative premises and greater openness when it comes to advocacy. 1 We commend the effort to reinstate power and politics in global health and agree that "a purely empirical evidence-based approach is a fiction, " and that such a view risks covering up "the role of politics and power. " But by contrasting this fiction with global health research "driven by crises, hot issues, and the concerns of organized interest groups, " as a "path we are trying to move away from, " Ooms is submitting to a liberal conception of politics he implicitly criticizes the outcomes of. 1 A liberal view of politics evades the constituting role of conflicts and reduces it to either a rationalistic, economic calculation, or an individual question of moral norms. This is echoed in Ooms when he states that "it is not possible to discuss the politics of global health without discussing the normative premises behind the politics. " 1 But what if we take the political as the primary level and the normative as secondary, or derived from the political? That is what we will try to do here, by introducing an alternative conceptualization of the political and hence free us from the "false dilemma" Ooms also wants to escape. "Although constructivists have emphasized how underlying normative structures constitute actors' identities and interests, they have rarely treated these normative structures themselves as defined and infused by power, or emphasized how constitutive effects also are expressions of power. " 2 This is the starting point for the political theorist Chantal Mouffe, and her response is to develop an ontological conception of the political, where "the political belongs to our ontological condition. " 3 According to Mouffe, society is instituted through conflict. "[B]y 'the political' I mean the dimension of antagonism which I take to be constitutive of human societies, while by 'politics' I mean the set of practices and institutions through which an order is created, organizing human coexistence in the context of conflictuality provided by the political. " 3 An issue or a topic needs to be contested to become political, and such a contestation concerns public action and creates a 'we' and 'they' form of collective identification. But the fixation of social relations is partial and precarious, since antagonism is an ever present possibility. To politicize an issue and be able to mobilize support, one needs to represent the world in a conflictual manner "with opposed camps with which people can identify. " 3 Ooms uses the case of "increasing international aid spending on AIDS treatment" to illustrate his point. 1 He frames the View Video Summary Implications for policy makers • By embracing the principles of aid effectiveness and cooperation, policy-makers, donors and implementers of health innovations will enhance the prospects of government being able to take those innovations to scale and bring about improvements in health services and systems. • Policy-maker engagement throughout the process of scaling-up health innovations is key to ensuring that previously externally funded innovations fit with national health priorities, policy frameworks and targets. • Government commitment to engage and work with donors and implementers can help to realise the aid effectiveness principles and improve health systems and services in low and middle-income countries, but this will take time.

Implications for the public
The internationally agreed aid effectiveness principles encourage greater cooperation between donors, implementers and governments that receive aid and can help those governments to adopt and expand the reach of health service innovations for mothers and babies, which received pilot funding from external sources. Such cooperation will contribute to providing health services that meet the needs of the population and improve public health. The principles include government ownership of innovations, aligning them with national health priorities, and coordinating donors and implementers. Moreover, if these three groups can develop a trusting relationship, through sharing information and creating transparency and accountability, it enhances coordination. Added to this, is recognition of the important contribution civil society can make through working with government to identify local health priorities and feasible ways to address them.

Key Messages
community opinion leaders and policy champions. [6][7][8][9][10][11][12][13][14][15] Health systems, political, economic and social contexts also influence whether innovations are scaled up including the capacity, training and attitudes of health workers and the strength of commodity logistics and supervision systems onto which new innovations might be layered. 6,9,10,13,16,17 Decision-makers' ideas and ideologies often shape which health issues are prioritised and which policies and programmes are financed within the constraints of a country's economic resources. Innovation adoption by local communities is influenced by health needs, beliefs, sociocultural values and norms, and access, which may be constrained by economic and geographical barriers. [18][19][20][21] We define scale-up as: government adoption and implementation of health innovations, increasing geographical reach to benefit a greater number of people beyond externallyfunded implementers' programme districts. We conducted a qualitative study to explore the factors influencing scale-up of MNH innovations in Ethiopia, northeast Nigeria and Uttar Pradesh, India. Specifically, we identified the main actions that implementers can adopt to catalyse innovation scale-up and the influence of geographical contexts on scale-up. 4,11 A strong emerging theme in our analysis, which we report in this current paper, was that donors, implementers and recipient governments' actions for promoting innovation scale-up also reflected many of the principles embraced by well-known international aid effectiveness agreements.  Table 1 provides a summary of six of the major principles embraced by these declarations. An emerging theme from the analysis of our interview data was that these factors were strongly associated with scale-up. It should be noted though, that there are several other aid effectiveness principles including: managing for results; South-to-South cooperation; private sector involvement; and gender equality and women's empowerment. While there has been progress towards adopting some of these principles, change has not been universal. 'Some unfavourable practices' remain, 30 including 'vertical' project funding focussed on specific health issues, rather than supporting broader health system strengthening, and donors continuing to set their own agendas which recipient governments are expected to accept. The Organisation for Economic Cooperation and Development (OECD) also acknowledges that aid predictability and donor harmonisation are often lacking; and governments have not met targets for domestic health expenditure, systems' strengthening and reforms, or drawn civil society into policy discussions. This paper aims to connect two fields of study: the scaleup of MNH innovations, that in their pilot phase had been funded by external donors, but where governments were involved in taking them to scale, and principles of aid effectiveness in LMICs. While several studies highlight the importance of innovations aligning with country priorities and that country ownership greatly increases the prospects of governments adopting innovations, 4,6,7,12-15,28 existing literature has not systematically analysed how donors, implementers and recipient governments' adherence to aid effectiveness principles affects the scale-up of externallyfunded innovations. These innovations sought either to develop existing, or introduce new approaches and many aimed to improve government MNH care services in rural areas (Box 1). Based on our analysis of our interview data, we argue that limited adoption of aid effectiveness principles by donors, implementers and recipient governments weakens the environment for scaling-up externally-funded health innovations.

Methods
We conducted qualitative, semi-structured stakeholder interviews in Ethiopia, northeast Nigeria and Uttar Pradesh, in these three diverse geographical settings, with a common feature of having some of the highest burdens of maternal and neonatal mortality in the world. We worked with researchers trained in qualitative methods, from the three countries and the United Kingdom, to develop a topic guide that we piloted at a workshop in Addis Ababa. After minor adaptations for each country, trained researchers used this guide when conducting 50 interviews for each setting in 2012 and 2013. The interviewees were purposively selected for their detailed understanding of what is involved in scaling-up MNH innovations funded by donors, and represented government departments, implementers and development partners working on MNH programmes in the settings. Of the donor-funded implementers, most worked for international nongovernmental organisations (NGOs) or large local NGOs. Others were US-based universities and for-profit consultancy agencies. To maintain our respondents' anonymity, we have not referred to specific organisations in this paper. Table  2 categorises interviewees by broad type, across the three geographical settings. The breakdown of interviewee types was similar in each setting, although in India, where the private sector has a significant role in proving MNH healthcare, we interviewed representatives from that sector. The MNH projects our interviewees referred to had typically received external funding for three to five years, and varied in scale from a few districts (India), local government areas (Nigeria), or woredas (Ethiopia), to many districts across multiple states or regions, and some were part of larger multicountry grants. Some implementers spoke of innovations they had developed which government was now scaling-up, or had incorporated aspects of into government practices; others were preparing innovations for scale-up. Yet mostly, implementers shared the many challenges they had faced when trying, but not succeeding in scaling-up innovations. All respondents gave informed consent before their interviews. Interviews were conducted in private spaces to ensure confidentiality and, where agreed, were recorded. Soon after each interview, interviewers wrote expanded field notes, 35 setting out details of the interview under topics reflecting our research questions and emerging themes, and incorporating respondents' direct quotes. Aid effectiveness issues emerged as a strong theme in our early interviews, which the research team further explored in later interviewees. By using investigator triangulation to compare and agree researchers' interpretations, each set of expanded field notes became the work of multiple researchers, thus helping reinforce the validity of the results reported. In addition, researchers from the United Kingdom and the three study countries attended an analysis workshop to reach consensus on interpretations and cross-country comparisons. Systematic analysis of the expanded field notes was conducted using a framework approach to code a priori themes and identify emerging themes in NVivo10 as we sought to examine the actions and factors that catalysed scale-up and the contextual factors enabling and undermining it. Aid effectiveness issues emerged in our data analysis which we related to key principles of aid effectiveness. The emerging themes were categorised by two researchers, separately, using an inductive analytic framework based on the aid effectiveness principles. When they were compared, the two analyses mostly concurred, but where there were discrepancies we returned to the data to check the most plausible explanation and sought inputs from co-authors. We also conducted checks by presenting provisional results to interviewees and country stakeholders in Lucknow, Addis Ababa and Abuja, who were invited to comment and confirm the accuracy of our messages. Our analysis and the quotes we have used reflect a balance of views from the different stakeholder groups, drawing out common views across the full range of stakeholders rather than focusing on a select few. Indeed, our analysis suggested there was considerable agreement on issues between different stakeholder groups. We received ethics approval from the corresponding author's institute; the Ethiopian Federal Ministry of Science and Technology; the Regional Health Bureaus of Amhara, Oromia, SNNP and Tigray regions; the Indian Council of Medical Research and SPECT-ERB in India; the Nigerian National Health Research Ethics Committee and Gombe State Ministry of Health.

Results
We examined ways that embracing each of six key aid effectiveness principles fosters scale-up of health innovations, and compared and contrasted the extent to which this had been achieved in the three settings, including the challenges faced. Table 3 presents some of the key features of the aid effectiveness principles enabling and undermining the scaleup of innovations in each of the three geographies, based on our analysis of all 150 respondents' accounts.
Country Ownership: "You Need Government Buy-in at Top, Middle and Bottom" Country ownership means that government leads a recipient country's development policies and strategies, to which donors align their funding. It also refers to strengthening government systems through donors' and implementers' technical support, and using recipient country systems, rather than introducing parallel ones. Our respondents explained that country ownership is fundamental to scalingup innovations; government engagement is required at all stages of an innovation's development, including design, implementation and evaluation. Without it, government would have little interest or stake in an innovation's success, making its adoption unlikely; 'Ultimately the owner of scaleup is [ Our respondents asserted that innovations should be embedded within health systems to have realistic prospects of being scaled. Yet, externally-funded implementers continued to introduce their own procedures since using weak government health systems was seen as delaying implementation, making it difficult for them to demonstrate the impact of an innovation to their funders. Our respondents acknowledged that this approach undermines country ownership, leaving innovations unsustainable and lacking the support required to make scale-up possible: '...we create parallel systems...but after the project ends it's the end of everything... ' (implementer, India). Our data revealed variations in the extent to which country ownership was potentially achievable across the three countries. Ethiopia's centrally organised control of donor-funded health programmes at federal level meant implementers required substantial government involvement and support -and with sufficient government interest, rapid scale-up of an innovation was conceivable. In Uttar Pradesh, if an innovation gained the support of influential state-level champions, scale-up was possible through mobilisation of state-level resources. For example, the support of a government official helped foster state government interest in a mobile phone tool to support frontline health workers. Moreover, donor priorities had less of an influence over policy implementation, particularly where they did not align with state government priorities. In northeast Nigeria, however, respondents suggested that government ownership of externally-funded innovations was more restrained. Although decisions on rural primary healthcare were decided at state and district level, low government prioritisation of rural primary healthcare has led to reliance on relatively high levels of donor-driven support for innovations: 'Government tends to decrease rather than consolidate funding…to priority areas    In northeast Nigeria by contrast, state governments were described as willing for donors to support MNH programmes with innovations; whether these aligned with government programmes was less of a concern. Yet, as our respondents explained, the fact that health is inadequately funded decreased the prospects of state government adopting and financing an innovation introduced by an externally-funded implementer. Transparency and Accountability: "…Trust Among Decision-Makers and Care Providers" Transparency includes donors being open about their programmes and their impacts, and providing recipient governments with data that aligns with national health information, thereby improving their accountability to those governments. Such transparency can foster scale-up since better information flows from donors and implementers to government, and coordinated information flows among multiple donors and implementers strengthens government's ability to make informed decisions about potentially scalable innovations. Further, better information sharing about innovations with government tends to foster trust, which interviewees suggested put development partners in a stronger position to advocate for their innovations to be scaled. This happened for a community care of sick newborns innovation in Ethiopia and a post-abortion care innovation in Nigeria. In the Nigerian example, an international NGO was transparent about evidence it found showing that a shortage of doctors able to administer post-abortion care in Nigeria was creating a backlog of women needing care, and then advocated for an innovation to train nurses in post-abortion care to help meet the need. Through being transparent about the evidence collected at each step, trust was built with policy-makers leading them to accept the link between this training and shorter waiting lists, which subsequently led to the inclusion of post-abortion care in the curriculum for nursing students so that the task shifting became institutionalised. In practice, implementers routinely established parallel monitoring and evaluation and information systems for innovations, rather than using -and potentially strengthening -government systems. Yet, respondents reported some progress towards better transparency. Ethiopia's Technical Working Group was described as enabling transparency -which increased the chances of innovations being scaledup: '[It's] the most important enabling factor' (implementer, Ethiopia). Similarly, respondents reported that the Uttar Pradesh Health Partners Forum was starting to 'encourage transparency' (implementer, India) and evolving into a 'sharing platform' (multilateral donor, India) about innovations, from which 'coordination between various actors…is likely to come' (implementer, India). In Nigeria, attempts to improve transparency -including strengthening federal and state-level mechanisms for coordinating innovations -were described during the interviews as in their infancy. Nevertheless, the intention to improve transparency existed: 'It's no longer business as usual. People are asking questions, people want to be informed' (multilateral agency, Nigeria).
Predictability: "Programmes Run Only as Far as Funding Is Available" Predictability includes donors being clear about how long governments can expect to receive funding and about anticipated future funding for an innovation, and also where possible, governments and implementers diversifying funding sources to create financial stability, so that innovations can continue and be scaled up. This may be more possible in middle-income countries like India and Nigeria, than in Ethiopia, which receives substantial external funding, but without some financial stability, it is difficult for recipient governments to plan long-term health spending commitments -including financing innovations introduced by externallyfunded implementers. Many interviewees highlighted the advantages of longer term and more predictable donor grants that, if forthcoming, would allow implementers to include a proper project planning phase, time and resources for effective advocacy and other scale-up activities, and for the innovation to develop and mature. It could also allow for committed time to support government to implement innovations at scale. We identified key ways in which each of the three main groups of actorsimplementers, governments and donorsmay enhance the prospects of scaling up MNH innovations, not only through their own actions, but also through working together.

Implementers
The steps which health programme implementers take to maximise the chances of their innovations being scaled are highlighted in existing scale-up literature. 4,6,7,10,[12][13][14][15]28 Implementers' flexibility to respond to changing policy directions helps maximise alignment, a point also raised by Bhutta and Aleem, 27 and something that donors might consider when deciding which groups to work with. While implementer actions and approaches, and the effectiveness of the innovation itself, are critical factors for scale-up, this paper also highlights the important role of recipient governments and donor agencies.

Government
Our data show how recipient governments can establish conditions that enable scale-up including: taking ownership of externally-funded innovations by engaging in their design and development; taking strong leadership of donor coordination mechanisms to improve alignment, harmonisation, transparency and accountability; and being responsive towards civil society. Adoption varied across our study settings, perhaps unsurprising given their markedly different economic and political contexts. Ethiopia, classified by the World Bank as a low-income country eligible for concessional loans, 36 is heavily reliant on external funding for its health system. While health policy Decision-making lies with national government, health system administration is being decentralised to woreda-level. The Ethiopian Government's high prioritisation of rural MNH, together with strong Ministry of Health leadership over donor programmes, despite the country being highly reliant on external health funding, meant implementers needed to seek high levels of government ownership to implement any health innovations. Additionally, the Technical Working Group was reasonably strong in coordinating donor health programmes and encouraging information sharing. These emerging factors increased the prospects of government scaling externally-funded health innovations, although a relatively weak civil society had limited influence over government's decision-making. In contrast to Ethiopia, India is classified as a lowermiddle income country, with the financial ability to borrow interest-bearing loans from the International Bank of Reconstruction and Development (IBRD). 36 While the Indian Government makes over-arching national policy decisions, the devolved health system, means that individual states have autonomy over local policy implementation and decide how disbursements from central funds are spent. In Uttar Pradesh, high prioritisation of MNH in rural areas through the National Health Mission provided substantial state resources for funding the scale up of selected health innovations, with some backing from influential state level champions, whereas low dependency on external funding meant donors had limited influence over health policies. The emergent, governmentled Health Partners' Forum was starting to improve donor coordination including better information sharing about innovations, while civil society was described as becoming a 'force for change' in influencing state government. Nigeria too is classified as a lower-middle-income country, yet its low per-capita income means that it is eligible to receive both concessional loans from the International Development Association and interest-bearing loans. 36 The Nigerian, the health system is partially decentralised, in that in some states, the state ministries of health make policy decisions, yet delays in the disbursement of funds often hamper implementation. In northeast Nigerian states, rural primary healthcare was considered largely donor-driven and funded. Reported problems of financing not following government commitments undermined the prospects of state governments adopting externally-funded health innovations, although like Uttar Pradesh, civil society had started to influence government decisions in some states.

Donors
Donor agencies have an important role in the scale-up of innovations since they have substantial influence over implementer behaviour. If donors choose to fund health issues that do not align with country-defined priorities, or continue to support vertical projects rather than broader health systems work, there is little to encourage country ownership. 27,30,32 Moreover, donor decisions affect the predictability of funding for innovations, in terms of whether they focus on shorterterm projects, are willing to fund longer-term programmes, or contribute to pooled health sector funding. 30,37 Donors' demands on their implementers have implications for scalingup innovations, including expectations about achieving results within ambitious timeframes, and how implementers report to them, what indicators are reported and whether country monitoring and reporting systems are embraced. 37 Donors can contribute to transparency by making apparent what they are funding, the impacts of their programmes and stimulating transparency among their implementers. 30,32,37 Beyond funding, donors can also: assist national governments to strengthen their capacity for ownership for innovations, avoid duplicating procedures, and harmonise with recipient country processes, 22 ensure alignment with national priorities and a long lead-in for planning an innovation's transition to government. 3 Limitations Our paper focusses on the aid effectiveness principles as key factors influencing the scale-up of innovations. Yet, there are multiple other factors -including the scalability of the innovations themselves, the capability of government to adopt and scale the innovation, embedding scale-up in project plans and generating and presenting robust evidence effectively. 4,11 While it may not be possible to generalise our findings beyond our focus settings, they offer a useful snapshot in time of three contrasting settings. We have also generalised about highly diverse set of donors and implementers, in terms of their focus and approach, as going into this in more detail was beyond the scope of this study. Additional research would be of value to understand these issues in other settings and unpack different approaches to influence scale-up. The nature of qualitative research means that the questions asked in interviews and the way they were analysed and interpreted may have be prone to some degree of subjectivity. Counterbalancing this, the researchers were external to the projects and thus had no specific interest in presenting them in a positive or negative light, which we hope has meant that our reflections are objective.

Conclusion
Our findings offer insights into how country ownership, alignment, harmonisation, transparency and accountability, predictability, and civil society engagement and participation can enhance the environment for scaling-up MNH care innovations in diverse settings, despite limitations and variations in the practical implementation of the different aid effectiveness principles outlined. Our study suggests that the links between these six principles of aid effectiveness and the scale-up of healthcare innovations are explicit to each of the three settings and would merit further investigation, across a wider range of countries to draw out specific considerations for recipient governments, donors and implementers.