achievingImpactAtScaleThe Family Health Division at the Bill & Melinda Gates Foundation strives to contribute to the discovery, development, delivery and dissemination of innovative solutions to long-standing health problems affecting poor women, newborns and children in developing countries.

Since the beginning of our work in family health, and as we invest in large-scale models of delivery of integrated solutions for women and children, we have been humbled and challenged by the complexity of spreading and scaling up health innovations in poor countries. Despite increased availability of funding for global health during the last decade and growing access to robust empirical evidence on the efficacy of innovations such as vaccines, immediate and exclusive breastfeeding, and skin-to-skin care—to name a few—the assimilation of these changes remains elusive.


We were initially puzzled by the realization that decades of investment in global health have left us with a vast graveyard of pilot programs that have rarely, if ever, been successfully scaled and, even less so, evaluated. This knowledge gap and our desire to identify creative solutions to the challenges of scaling up, led us during the last two years to the methodical exploration of these complex phenomena. In addition to our own inquiry, we have commissioned original research from various research organizations and experts. We have also assessed the ways in which we apply our own knowledge and capacity in the design and evaluation of large-scale health programs. In the process, we have been fortunate to engage other partners and practitioners in governments, industry, and international development that face similar challenges.

We have learned that the achievement of measurable impact from the deployment of health innovations will require sustained efforts to promote social and behavior change. In effect, the spread of highly efficacious solutions like kangaroo mother care, clean cord care, and exclusive breastfeeding will not only require changes in the practices and organizational forms of existing delivery systems, but we will also have to tackle long-standing community beliefs and norms, organizational inertia and counterproductive social networks, and individual and collective disincentives for the adoption of new ideas, mental models, and practices.

As an example of the path we are determined to tread as we move forward in the quest for impact at scale in family health, last November Melinda Gates convened a gathering of experts from multiple fields and disciplines to discuss the frontiers of social science that will allow the design and deployment of context-specific, scalable, and replicable solutions that may help spread health innovations in low-income countries. This meeting was the result of an explicit effort on our part, as we mature and adapt to a changing environment, to improve our ability to share knowledge and evidence within our global community, hear the voices of policy-makers, researchers and implementers in public and private sectors, and learn from the experiences of those who have treaded this path before.

In our view, achieving change at the scale that will be required to significantly reduce the burden of disease among women, newborns and children will demand innovative solutions from a myriad of social agents and organizations currently involved in the production of health, ranging from global organizations to households in poor communities. However, we also believe that the achievement of health impact at scale in the developing South will also require the aggregation and networking of the resources—particularly knowledge and human ingenuity—the voices, and the capacities of many organizations around the globe.

The sources of some of the disruptive and sometimes deceivingly simple solutions to the challenges of scaling up may lie outside the traditional realm of the health sciences. The exploration, identification, adaptation, and application of such solutions will likely require the facilitation of dialogue between multiple and disparate sectors and organizations, and the linking of social networks that can thrive through experiential learning and knowledge sharing. We are committed to contributing to the convening of these new organizational forms and to the purposive dissemination of knowledge and evidence acquired through these means. Also, as part of this process we aim to contribute to the establishment of further connections between sources of innovative know-how and those responsible for the formulation, implementation and evaluation of public policy in health.

Looking back at the last 50 years of investment in development and the recent decade of impressive growth in official and philanthropic assistance in global health, it may be worth noting that approaches like the ones mentioned in this essay have emerged aft er the sobering realization that no single organization holds all the resources or solutions to tackle the challenge of achieving health impact at scale. In the current global economic environment, the way forward inevitably requires leveraging the knowledge, creativity, and capacity within our imperfect markets and governmental hierarchies while simultaneously engaging the power of human and organizational networks to effectively drive social and behavior change.