Richard Smith: Five examples of scaling up

Richard SmithDeveloping interventions that work to, say, reduce malaria, combat obesity, or prevent cardiovascular disease is hard, but scaling them up to benefit whole populations is harder. Yet the interventions must be scaled up to make any important difference to global problems like malaria, obesity, and cardiovascular disease. The Oxford Health Alliance meeting in Delhi last month heard about four examples of successful scaling up—and I’ve added a fifth.

The first example was from Abu Dhabi, which Oliver Harrison, a British doctor, and colleagues have turned into a “living laboratory.” They are aiming to measure the risk factors of every adult in the country, including blood pressure and lipids, and give them personal treatments, plans, and targets. They have begun with a cohort of almost 200 000 and have screened 94% of them. All of their data will be entered into a computer and monitored, but the programme is not all about individuals. The database, which shows high levels of risk, provides a stimulus and a way of monitoring public health programmes of promoting physical activity, working with schools and workplaces, improving urban planning, working with the food industry, and the like.

The Abu Dhabi programme costs $15 per head, but Harrison, both a visionary and a former McKinsey consultant, thinks it can be done for as little as $1 per head using cheaper staff and different methods—so meaning that it could be feasible in some poorer countries.

MEND (Mind, Exercise, Nutrition, Do it) is a community based programme for preventing and treating childhood obesity devised at Great Ormond Street that I’ve blogged about before. Paul Sacher, a cofounder of MEND, described the original programme and how they have scaled it up using software, staff in gyms rather than health professionals, and flexible business models. They have managed to reach some 30 000 in the UK, but that’s still a tiny percentage of all the overweight and obese children.

I’ve also blogged about Agita Mundo, a programme that began in Sao Paolo to encourage physical activity. Victor Matsudo, who originally was an orthopedic surgeon, began locally and through fun, branding, partnerships, and highly effective communication, including clever use of the internet, created momentum that engaged politicians, which led to changes in the environment that encouraged walking, cycling, and other forms of physical activity. Matsudo then spread the programme nationally, regionally, and eventually globally, signing up over 20 countries and about 5 millon people for a recent day of physical activity.

Discovery is a South African based insurance company that has developed a programme to pay not for treatment of sickness but to promote wellness. People in its Vitality programme all have their health status benchmarked and are then set personal goals to improve it and are rewarded—with a wide variety of rewards including plane and movie tickets—for healthy behaviour such as exercising at a gym. The more they exercise the more rewards they receive. There is also now a programme that rewards the purchase of healthy foods.

Vitality is not profitable in itself, but in order to enter the programme you must purchase another Discovery product—for example, health insurance. The benefit to Discovery is that it retains people who do well on the Vitality programme, and they have lower admission rates to hospital and lower costs and shorter stays when they are admitted. These add up to substantial savings for Discovery, increasing the company’s profitability.

A fifth example comes from UnitedHealth Group, the company I work for, and was recently described in the New York Times. The programme aims to scale up an intervention to prevent diabetes shown to work more than a decade ago in a study funded by the National Institutes of Health. People with prediabetes—some 57 million people in the US, 85% of them unaware of their condition—work in groups with a trained lifestyle coach in 16 sessions to eat healthier diets, exercise more, and learn about other behavioural modifications. United has teamed up with the YMCA to implement the programme and it’s free to those enrolled in United health plans through their employers. Pilots conducted by United show that the health costs of these people can be dramatically reduced. United is also partnering with Walgrens, a pharmacist that covers the US, to improve the care of those with diabetes—again based on evidence based trials.

What do these programmes for scaling up have in common? Vision, an evidence base, tight management of data, attention to costs, clever communication, and business like methods.

Competing interest: I work for the UnitedHealth Group but was not involved in developing the programmes for preventing and treating diabetes. I have shares in the company, and if the programme does well it might raise the share price and I might benefit.