🔍💡 Scaling up in public health: it is neither natural nor automatic, but an active, costly, and political process that stakeholders must lead, equip, and advocate for. #ScalingUp #PublicHealth🧩🚀 Scaling up an effective programme means managing fragile funding, competition between interventions, turnover, and issues of fidelity/adaptation, all while keeping equity in focus. #Prevention
📌 This text very concretely illuminates what it means to "scale up" an intervention in France: real strategies, involved stakeholders, invisible activities, barriers, and levers.
For a regional programme manager, an association coordinator, an ARS project manager, or a PMI executive, it helps to anticipate what a national or regional deployment really entails (organisation, funding, governance).For a network, a lead structure, or a local authority, it provides operational benchmarks to structure its dissemination, support, and monitoring system.
Source: 📒 Experiences and perceptions of scaling up a public health intervention: interviews with a variety of French stakeholders
✍️ Nolwenn Stevens · François Alla · Henri Bergeron - Canadian Journal of Public Health, 2026, volume 117
📜🔗LINK to the source
Number of pages: 20
1. Analytical summary
1.1. Context and issues: scaling up as a blind spot in evidence-based policies
The article starts from the observation that in France, as elsewhere, many public health interventions remain confined to local experiments, while others are deployed without solid evidence, and many attempts to scale up fail or lose momentum.
The authors remind us that scaling up is central to realising evidence-based health policies, but it is far from being an automatic extension of political decision-making or proof of effectiveness.
They situate the study in the recent French context: mission to reform public health, Article 51 of the LFSS 2018, portal for proven and promising interventions from Public Health France, SFSP dynamics on the deployment of proven interventions.
The objective is to better clarify what "scaling up" (SU) is, to identify the strategies actually used, to describe the concrete processes, and to identify the factors that promote or hinder this scaling up.
The study is based on 22 semi-structured interviews with 27 practitioners involved in the scaling up of 19 complex population interventions (CPS, addictions, parenting, care pathways, etc.), at the intersection of associative, health, educational, medico-social, and institutional environments.
1.2. Operational contributions: a detailed mapping of strategies, activities, catalysts, and barriers
The results show that scaling up is an active, progressive, and multidimensional process that relates to territorial expansion, sustainability, and the real-world adequacy of interventions.
Three major expansion strategies (opportunism, sprinkling, systematisation), several options for sustainability (empowerment, cultural adaptation of practices) and a constant tension between fidelity to the model and adaptation to contexts are described in detail.
The authors identify four types of favourable decisions (funding, support, commitment, adoption), two main organisational structures (pyramidal, radiating) and eight essential scaling activities (communication, coordination, contracting, training, tooling, updating, facilitation, monitoring).
They highlight six catalysts (trust, innovative character, operational realism, collective dynamics, political opportunities, facilitating individuals) and six inhibitors (resource-intensive interventions, underfunding, instability of actors, decision-making polyphony, short-term funding, competitive market).
Finally, the discussion links these results with the sociology of public action, the approaches of 'solution science' in intervention research, scalability/scale-up frameworks and medical-economic issues, opening avenues for better thinking about scaling decisions.
2. Key points of the document
Scaling, an active and multidimensional process
Scaling up is defined as a non-spontaneous process that requires planned efforts aimed at increasing geographical coverage, ensuring sustainability and making the intervention feasible in real conditions, with structured adaptations.
The authors distinguish the dimensions of space (from local to international), time (sustainability, support mechanisms) and reality (testing in different territories and populations, adjusting to field constraints).
Key pages: definition and dimensions of the MAE (p. S23–S25).
Three strategies for territorial dissemination: opportunism, sprinkling, systematisation.
The experimenters describe strategies ranging from a lack of planning (opportunism) to the voluntary dispersion of the intervention across different territories (sprinkling) to an ambition for near-universal coverage (systematisation).
These choices are linked to ideological positions (strict preservation of the model vs integration into ordinary practices) and to resource constraints or funder requirements.
Key pages: strategies for territorial expansion and debates on integrity/adaptation (p. S26–S28).
Eight central activities to organise for successful scaling.
The article formalises eight essential activities: communication with beneficiaries, multiplier actors, and decision-makers; multi-level coordination; contracting (funding, intellectual property, quality obligations); training of operators; tooling (guides, supports, monitoring tools); updating of content; facilitation (support, hotline, mentoring); qualitative and quantitative monitoring.
These activities, often underestimated and underfunded, structure the function of the intervention's 'support structure' and condition the quality of deployment.
Key pages: table of MAE activities (Table 3, p. S28–S29).
Six catalysts and six inhibitors: a realistic view of the conditions for success.
Among the catalysts, the article emphasises: the label "proven", positive evaluative results, adherence to good public health practices, the innovative nature, strong alignment with field constraints, collective dynamics, alignment with the political agenda, and the role of highly committed or influential individuals.
On the side of barriers, the following stand out: the human and financial cost of interventions, the underfunding of scaling functions, the turnover of actors, the absence of a "harmonising authority", short-term funding, and competition between themes, interventions, and stakeholders.
Key pages: MAE catalysts (pp. S31–S32) and inhibitors (pp. S32–S33).
A critical questioning of evaluation frameworks and political choices.
The authors highlight that evaluation is recognised as essential, but rarely implemented due to lack of time, resources, and skills, and that sustainability is very rarely evaluated.
They question the external validity of results from derogatory experimental devices (Article 51, experiments), and point out an "economic taboo": the medico-economic dimension of MAE is central in discourse, but very little explored in practice.
Key pages: section on evaluation, experimental devices, and discussion on medico-economic and political issues (pp. S30–S34).
3. Action pathways for local actors.
Formalise a strategy for dissemination and coverage from the pilot phase (pp. S26–S28).
For an intervention holder or a local authority, it is useful to clarify early whether the objective is opportunistic dissemination, a sprinkle to occupy the ground, or a systematisation aimed at maximum coverage, and to specify the criteria for prioritising territories.
This allows for negotiating funding and partnerships on a more transparent basis, and adjusting the expectations of local actors.
Establish a 'support structure' with a clear mandate and dedicated resources (p. S28–S30)
For a national association, an ARS, a federation, or a GIP, the creation of a formalised support structure (pyramidal or radiating) allows for the centralisation of coordination, training, tooling, facilitation, and monitoring.
This structure must have dedicated time, skills in training engineering, monitoring-evaluation, and network facilitation, and benefit from multi-year funding.
Tooling fidelity/adaptation: define the 'key functions' of the intervention (p. S27–S28)
Local actors can work, with the designers, to explicitly identify what is non-negotiable (principles, sequences, facilitation methods) and what can be adapted (examples, materials, logistical formats) to facilitate ownership without diluting the effect.
This work can rely on existing tools such as ISAT (Intervention Scalability Assessment Tool) which integrate dimensions of fidelity/adaptation and implementation infrastructure.
Integrate simple monitoring into field routines (p. S29–S31)
Local teams can build minimalist dashboards: number of sessions, audiences reached, trained actors, dropouts, difficulties encountered, simple measures of satisfaction, to document coverage and identify areas of fragility.
This provides stakeholders with concrete arguments in discussions with funders and allows for anticipating support or adjustment needs.
Work on embedding in the political agenda and alliances (p. S31–S34)
Programme managers can map agendas (local, departmental, regional, national) and identify windows of opportunity where the intervention meets a stated priority (bullying, addictions, mental health, social health inequalities, etc.).
They can also mobilise 'boundary entrepreneurs' (actors capable of operating across multiple domains: scientific, political, associative) to advocate for the cause and secure decisions for support or adoption.
4. Additional references
Practical guide to scaling up population interventions
Milat A, Lee K, Conte K, et al.Intervention Scalability Assessment Tool: A decision support tool for health policy makers and implementers.Health Research Policy and Systems, 2020.
Although dated 2020, the ISAT is up to date, widely used, and still referenced in 2024–2025 as a central tool for assessing the scalability of an intervention (parts A, B, and C covering relevance, implementation modalities, sustainability). 6https://pmc.ncbi.nlm.nih.gov/articles/PMC6942323/
Recent synthesis on frameworks for scaling in public health
Stevens N, Alla F, Bergeron H.Synthesis of conceptual, methodological and pedagogical works on scaling up public health interventions.Canadian Journal of Public Health, 2025 (online).
This review (2000–2021) proposes a new definition of scaling up, identifies 29 success factors, 28 obstacles, and 10 phases of work, useful for situating the present article within a broader landscape.https://pubmed.ncbi.nlm.nih.gov/41184972/
5. Cross-sectional analysis — values of Health Practices
Literacy: the document remains dense, academic and conceptual, without tools directly designed for audiences with low health literacy; it is aimed more at experienced professionals.
Empowerment: the voice of end beneficiaries (citizens, patients, users) is very rarely present; the analysis focuses on institutional, associative and professional actors involved in the MAE.
Participation: participation is mainly mentioned through collective dynamics between structures and teams, rather than through co-construction mechanisms with target audiences.
Community health: the community dimension appears indirectly in certain interventions (priority neighbourhoods, CPS programmes, parenting), but the reflection remains focused on governance and systems rather than on autonomous community action.
Ethics: the article mentions issues of equity, proper use of resources, and good public health practices, but does not address cultural or social biases in depth.
Human rights: equity and the reduction of inequalities are present in the background (population focus, necessity to move beyond the experimental status), but the explicit reference to human rights is limited.
Intersectorality: several interventions involve health, education, social, associative, and local authorities, but the analysis does not detail formalised intersectoral mechanisms such as 'health in all policies'.
Partnership: collaboration models (support structures, networks, pyramid/radiating configurations) are clearly described, with attention to roles and task distribution.
Combating discrimination: the text does not explicitly address discrimination (gender, origin, disability, sexual orientation); diversity and non-judgment are not at the heart of the analysis.
6. Assessment of the reliability of the resource
Scientific relevance
Quality of sources and theoretical grounding: the article draws on a wealth of international literature on scaling up, diffusion of innovations, intervention research in population health, public action sociology, and management/marketing sciences.
Methodology: rigorous qualitative study, 22 interviews, 27 stakeholders, 19 varied interventions, structured thematic analysis linking pre-existing theoretical framework and inductive openness, with abductive inference and collective discussion of results.
Relevance of the data: interviews conducted in 2023, article accepted in 2025 and published in 2026, which makes it very up to date with respect to French institutional dynamics (article 51, SPF portal, SFSP procedures).
Limitations: absence of triangulation through observation or documentary analysis, focus on interventions already identified as ongoing MAE, no systematic quantitative analysis of scaling effects.
Operational relevance
Direct usability: the text provides a detailed mapping of the activities and organisations necessary for MAE, very useful for designing a deployment system, but without providing ready-to-use tools (checklists, contract templates, monitoring grids).
Transferability: even though the grounding is French, the described logics (strategies, catalysts, barriers) are easily transposable to other contexts, provided that institutional references are adapted.
Target audience: mainly suitable for programme managers, executives, project leaders or researchers; less directly accessible for field workers without support.
Overall, the resource isscientifically reliableandoperationally useful, provided it is supplemented with dedicated guides/tools and translation support for teams unfamiliar with intervention research.
7. MCQ — 5 questions
Part 1 — Questions (without answers)
Question 1 (p. S23–S25)
In this article, the scaling up (MAE) of a public health intervention is primarily described as:
a) An automatic extension of a significant intervention
b) An active, progressive, and multidimensional process
c) A simple increase in the budget of an intervention
d) A transfer of competence from researchers to elected officials
Question 2 (p. S26–S28)
Among the identified territorial expansion strategies, which one explicitly aims to disseminate the intervention "a little bit everywhere" without aiming for comprehensive coverage?
a) Systematisation
b) Opportunism
c) Sprinkling
d) Targeted concentration
Question 3 (p. S28–S29)
Which of the following activities is part of the eight core activities of scaling described in the article?
a) Systematic external financial audit
b) Contractualisation between involved actors
c) Annual rotation of facilitation teams
d) Substitution of all existing tools
Question 4 (p. S31–S33)
Among the barriers to scaling described by the experimenters, which one is highlighted as a major limitation?
a) The absence of any political interest in health
b) The excess of available time among actors
c) The human and financial cost of interventions and MAE
d) The excessive stability of local teams
Question 5 (p. S30–S34)
What do the authors highlight regarding the experimental devices (e.g. article 51) used to evaluate interventions and their scaling?
a) They always guarantee excellent external validity
b) They are useless for scaling
c) They create favourable conditions that do not always reflect the 'real world'
d) They replace the need for any other form of evaluation
Part 2 — Commented correction
Question 1 (p. S23–S25)
In this article, the scaling up (MAE) of a public health intervention is primarily described as:
✅ Correct answer: b) An active, progressive, and multidimensional process
📝 Explanation: The authors emphasise that MAE 'is not self-evident' and does not constitute the natural evolution of an intervention, but a process that requires deliberate efforts in space, time, and reality.
Question 2 (p. S26–S28)
Among the identified territorial expansion strategies, which one explicitly aims to disseminate the intervention "a little bit everywhere" without aiming for comprehensive coverage?
✅ Correct answer: c) Sprinkling
📝 Explanation: The sprinkling strategy seeks to disperse the intervention across different territories without aiming for total coverage, focusing on presence in many places rather than on exhaustiveness.
Question 3 (p. S28–S29)
Which of the following activities is part of the eight core activities of scaling described in the article?
✅ Correct answer: b) Contracting between involved actors
📝 Explanation: Contractualisation (agreements, funding contracts, integrity compliance clauses) is identified as one of the eight essential activities for MAE, alongside communication, coordination, and training.
Question 4 (p. S31–S33)
Among the barriers to scaling described by the experimenters, which one is highlighted as a major limitation?
✅ Correct answer: c) The human and financial cost of interventions and MAE
📝 Explanation: Interventions are described as being "resource-intensive" in terms of time, training, support, and follow-up, and MAE activities are frequently under-resourced, which significantly hinders deployment.
Question 5 (p. S30–S34)
What do the authors highlight regarding the experimental devices (e.g. article 51) used to evaluate interventions and their scaling?
✅ Correct answer: c) They create favourable conditions that do not always reflect the "real world"
📝 Explanation: The authors note that these derogatory devices strongly control the conditions (site selection, choice of operators, strict protocol), which can blur external validity and raise questions about what is actually observed.
8. Frequently Asked Questions (FAQ)
Who is this document primarily aimed at? (p. S21–S24)
It is primarily aimed at intervention designers, association coordinators, institutional programme managers, ARS executives, PMI services, care structures, and researchers involved in scaling population interventions.
What interventions have been studied to document scaling? (p. S25–S27)
Nineteen interventions are analysed, covering various fields: physical activity (I‑CAPS, Grand Défi Vivez Bougez), addictions (PRIMAVERA, UNPLUGGED), psychosocial skills (PRODAS, SE&SR, GBG, COM’IN), parenting (PANJO, PSFP), nutrition, care pathways (CECICS, OCTAVE), menstrual poverty, etc.
What profiles of actors were interviewed? (p. S24–S25)
The 27 experimenters are designers, referents, operators, trainers, evaluators, supporters, from associations, national agencies, care structures, companies, with levels of action from departmental to national.
What are the main levers identified to facilitate scaling up? (p. S31–S32)
The levers include: a status of 'proven' interventions supported by positive evaluations, strong operational realism, an attractive innovative character, solid collective dynamics, alignment with the political agenda, and the role of highly committed and well-connected individuals.
What major obstacles should programme leaders anticipate? (p. S32–S33)
They should anticipate interventions that are very resource-intensive, recurrent underfunding of scaling functions, high turnover of actors, the absence of a unifying political body, short-term funding, and a competitive context between interventions and themes.
How does the article help to structure a scaling-up mechanism? (p. S28–S30)
It proposes a clear breakdown into decisions, organisations (pyramidal/radiant structures) and eight key activities (communication, coordination, contracting, training, tooling, updating, facilitation, monitoring), which can serve as a framework for organising an operational system.
What links are made with intervention research and the 'science of solutions'? (p. S33–S35)
The authors show that scaling up questions the way intervention research is conceived: science of ready-to-use interventions or science of solutions to be recomposed according to contexts, and invite the articulation of MAE with scalability and systems-type approaches.
9. Rewriting in Easy-to-Read Language
9.1. Easy-to-Read Summary
Easy-to-Read Title
Scaling up a health programme
Context and issues (simple)
The authors talk about health programmes that work well, but often remain only in one place.
To help more people, they need to be used in many other locations.
This is called 'scaling up'.
It is not automatic. It requires work, time, and money.
The authors spoke with people who have already done this work in France.
Operational contributions (simple)
The text explains how programmes can spread across multiple territories.
It describes the tasks to be done: inform, train, coordinate, follow up, adapt the tools.
It shows what helps: a solid, realistic, well-evaluated programme, supported by decision-makers.
It also shows what is blocking: lack of money, team changes, competing projects.
This text provides ideas for better organising and funding scaling.
9.2. Key points FALC
Point 1 – Scaling is real work
Scaling is not just copying a programme.
It requires planning, adapting, and monitoring the programme over time.
One must consider the territory, the teams, and the resources.
Point 2 – Three ways to disseminate a programme
By opportunity: seizing opportunities as they arise.
By 'sprinkling': the programme goes a bit everywhere, but not everywhere.
By systematisation: we want all targeted structures to use it.
Point 3 – Eight important tasks
Inform stakeholders and the public.
Coordinate teams at different levels.
Make contracts between structures.
Train professionals.
Provide ready-to-use tools.
Update content.
Support teams on the ground.
Monitor what is done and the results.
Point 4 – What helps
A programme recognised as effective.
A programme feasible in the reality of the field.
Motivated and well-connected stakeholders.
A topic that aligns with current political priorities.
Point 5 – What blocks
A programme too heavy for the teams.
Not enough money for dissemination and monitoring.
Many changes of people.
Funding is too short.
Programs that compete with each other.