Living Health Systems

What if every financial decision made the world a healthier place?

What does ‘Scale Up’ really Mean?

This post was revised and edited on 1st July 2025.

‘Scale Up’ is a common phrase that is often seen in climate finance.

If you apply for a grant for instance, it’s highly likely you will have to talk about scale. In the Green Climate Fund applications, for instance, there is a section that asks about ‘Scalability and Potential for Transformation’.

A search on the Carbon Brief website found 104 mentions of “scale up”, 1206 mentions of the word “scale” and 6 mentions of the word “scalable”.

If you want your work to have impact, at some point you will need to consider scale.

Variations on the phrase scale up include

  • Scalable;
  • Small-scale;
  • Large scale;
  • Micro scale;
  • At scale;
  • Scalability.

What do these phrases really mean?

How does scale up connect to climate resilient health systems? What are donors and impact investors asking for when they talk about scale? And is that request reasonable, given local contexts?

Context

Let’s start with the phrase in context.

Below are a few examples of how scale up (with or without the hyphen) appears in the documents of some critical grant makers and leaders in climate change and health. Emphasis in italics has been added to the original quote.

  • The Adaptation Fund application. “…how the sustainability of the project/programme outcomes has been taken into account… (how) benefits achieved with the help of the project/programme should be sustained after its end and should enable replication and scaling up with other funds after its end” [1].
  • Four large multilateral climate funders made a common statement on their aims [2], which included
    • “mitigate financial risks, lower investment costs, and scale up access to finance”
    • “aim to … scale up projects”
    • “deploy our collective resources at a larger scale”
  • Wellcome Trust. “In 2024, we will fund projects that generate context-specific evidence using community knowledge and experiences to deliver actionable policy outcomes that can be scaled to multiple settings” [3].
  • World Bank. “enhanced cooperation between (IMF and World Bank) will foster country-driven partnerships, galvanize policy changes, and scale up investments to meet countries’ climate needs” [5].

The World Health Organization tends to use the phrase when referring to health emergencies due to global warming. “…heatwaves, wildfires, floods, tropical storms and hurricanes (…) are increasing in scale. It remains challenging to accurately estimate the scale and impact of many climate-sensitive health risks …determine the risks and scale of these health threats” [6].

Scale up is also commonly used in health development without reference to climate warming. Does it mean the same in climate finance as it does in health development?

Health and Scale-up

Let’s start with a look at how World Health Organization (WHO) frame ‘scale up’ in their own work.

The WHO created “ExpandNet” in 2003, a global network that supports the expansion of successful health interventions so that such interventions can reach more people, more quickly, and more sustainably and achieve equitable access to quality care . ExpandNet has a raft of documents on how to health projects and programs [7].

Because any innovation is a package of activities and not just one thing, ExpandNet argues that scaling up is a “complex organizational, managerial, political and policy task, rather than a technical challenge, and requires strategic planning and management” [8].

Programme managers responsible for leading a scale up (e.g. a roll out):

“are faced with an enormous challenge to implement the innovation on a large scale with few resources and in health systems that may be characterized by weak capacities and multiple, pressing priorities. Under such circumstances, success (requires balancing…) desired outcomes and practical realities and constraints. It also requires a planning process that is consistent with building national health systems’ capacities rather than imposing additional burdens on fragile public sector systems” [9].

There are four key points here:

  1. Scale up must fit within an existing envelope of financial, human, and other resources. Whether an innovation package has ability to scale is partly determined by these realities and constraints.
  2. An innovation package should not undermine the performance of other services in the health system: “Promising initial project results often lead to pressure to scale-up the innovation before its feasibility and outcomes have been fully demonstrated. Proceeding without (proof of implementation in context) can lead to… wasted resources, missed opportunities to make progress on other fronts and a loss of credibility” [10].
  3. A decision has to be made on whether an intervention is worth scaling. Cautionary time taken to assess whether there is genuine value in scaling, or not, is time well spent.
  4. Scaling up must ensure human dignity, respond to the needs and rights of vulnerable groups, include gender perspectives, and promote equitable access to quality healthcare services.

Different types of scale up are discussed by ExpandNet:

  • Vertical. When policy, political, legal, regulatory, budgetary or other health system changes are made to institutionalize an innovation package nationally, or at provincial or district or community health system “levels”;
  • Horizontal. Meaning expansion or replication of an innovation package at different geographic sites or extended to serve more people or different population groups;
  • Diversification. When an organization adds-on products and services to the original package;
  • Spontaneous. Meaning diffusion without deliberate guidance plan on anyone’s part.

This is a very short summary of the ExpandNet approach to scale up and provides a useful starter for thinking about, and dealing with, scale up within health systems

How does this compare to climate finance?

Climate Finance and Scale Up

The Green Climate Fund (GCF) published a report called “GCF- SAP CREWS Scaling Up Framework for Early Warning” in June 2023 [11]. All quotes in this section are taken from this document.

Let’s use this document to get an insight on how a climate change grant maker uses the phrase.

The report sets out a framework to enable the Climate, Risk & Early Warning Initiative (CREWS) at the World Meteorological Organisation (WMO) to access more funds from the GCF. CREWS is a multilateral fund for ‘most vulnerable countries’ to improve its early warning system for risk weather such as flash floods, tsunami, drought conditions in selected countries.

The framework aims to scale up previously successful projects in early warning systems. No definition of scale up is given but the process is a funding fast-track that “accelerates approvals, strengthens partnerships in pursuit of common goals, and replicates successful EWS efforts”.

EWS (the innovation) is considered a package of activities, which comprises weather observations & forecasting; disaster risk knowledge for weather professionals; warning dissemination to the public; disaster preparedness & response.

The EWS package is considered to ‘scale in three ways:

  • Horizontally across a geography (Quantitative scaling);
  • Functionally meaning more add-on to address capacity “gaps” in the “early warning value chain”;
  • Institutional capacity strengthening e.g., “(national) strengthened or establishment of EWS strategic plans, increased budgets, human resource, and quality management systems”.

Human need (compare human dignity in ExpandNet) is important: “the needs and assessment of vulnerable target population will be aligned… evidence of systems for resilience linking to users – e.g. project engagement with the last mile actors” is part of the fast track process.

The framework goes onto consider scale-ability: “scaling-up project(s) can take place at any time… as long as the success criteria are met and demonstrated… (as long as a) project can prove scalability”.

The fast track process is set out in 7 steps. The first step is for CREWS to identify possible projects to scale. The third step is to identify the Accredited Entity to make the actual application. In other words, the process is led by the innovation package and the WMO rather than the country or the existing resource envelope available nationally.

This is made clear in the following statement: “once projects are prioritized and countries show interest… CREWS implementing partners will provide necessary technical advice and/or support to the NDAs (National Designated Authority) and AEs (Accredited Entity) in detailing the project idea”. These statements appear to place highest value on speed and volume.

Step 3 is the identification of the Accredited Entity that “will be carried out by the GCF Secretariat with support of CREWS Secretariat… entails close consultations between GCF, CREWS, and CREWS implementing partner for the selected projects”. The United Nations Office for Disaster Risk Reduction, WMO, and World Bank/Global Facility for Disaster Reduction and Recovery (GFDRR) [a multi-donor partnership that makes grants] serve as Implementing Partners of the CREWS Initiative (12). This seems curious – where is country and local context in all of this?

“The roll-out phase (of the Framework) will involve the fostering of new partnerships, leveraging of additional resources to integrate innovative financing opportunities” – the EWS seems to consider financing as something that happens through/by means of, scale up.

Compared to ExpandNet the language of the GCF is quite different. Replication (not adaptation) is important. Replication was found 7 times in the document. Value chain is discussed (again 7 times) and value proposition (3 times). “Ready-to-go fundable projects” is considered a beneficial outcome of the collaboration between WMO CREWS and GCF. The focus seems to be on volume and speed with the domestic resource envelope and the grassroots realities a secondary consideration.

Reality Bites

Using these two approaches to get a quick insight, does health development think about scale up in a drastically different way from climate finance? Some clear themes pop out:

VOLUME.

Both GCF and ExpandNet consider that volume is part of scaling in the sense of more: more products, or more services, to more people than presently the case. For GCF, however, volume seems to trump local absorptive capacity which ExpandNet is much more careful to assess first, before deciding on whether more volume is desirable and do-able.

Besides local capacity, another problem with volume is that more of something means more resources (human, ecological, manufacturing etc) are needed to produce it or deliver it. Until humans have found a way to live and work at pollution zero, volume contributes to climate warming, which is the problem that we are trying to solve. The paradox of volume for volume’s sake means that the goal of truly clean healthcare (or energy, or food, or transportation or buildings) can never be attained.

SPEED/URGENCY.

Speed comes out clearly with GCF. There is a sense that humans have to get to volume as fast as possible. Speed=survival is a narrative found in many climate-warming articles. Notably though, ExpandNet is much more cautious and considers that initial speed can be long term counterproductive by wasting valuable local resources. Consider the medical emergency room team who ‘go slow to go fast’.

Caution in healthcare is integral to speed and not contrary to it.

FINANCIAL SUSTAINABILITY.

This is discussed in both documents. However, ExpandNet considers financial sustainability as something to assess and understand before scaling. GCF seems to consider sustainability as something to do during and/or by means of scale up. This may be down to financing. GCF is financed through periodic donor replenishment while healthcare as a sector tends to be underfunded, and so ExpandNet may be assuming that external funding is temporary.

HUMAN DIGNITY/NEED.

Human dignity and human need are referenced in both documents. While community needs aren’t initially obvious in the GCF document, it becomes more apparent in the decision making criteria detailed in the framework.

WHAT ABOUT THE LOSERS?

Neither document talks about the losers and the winners. When an innovation package is produced or implemented at greater volume, over a greater geography, to more people, then a status quo has changed. In any status quo are the current winners and losers. An innovation package creates a new set of winners and losers. Scale up is a story of power and politics and this aspect is ignored. Ignoring the losers means you do not understand where, and with whom, lies resistance to change. Ignoring the winners means you may be unwilling to see where power is embedding. And when building climate adaptive and resilient health systems, you do not therefore see where and how to bring in ‘the losers’ to be part of the story of transformation.

And so…

As health systems work closer with climate finance, there will be an imperative to scale up interventions and innovations. Climate finance will emphasise speed and volume so healthcare should make the case for going slow to go fast. This is ultimately faster than wasting decades of time later. Doing volume in any aspect is more than replication in different locations, rather involves complexity in politics, management, leadership, and financing. Make caution an integral part of speeding up health system adaption and mitigation.

References

[1] The Adaptation Fund https://www.adaptation-fund.org/wp-content/uploads/2021/05/Instructions-for-Preparing-a-Request-for-ProjectProgramme-Funding_Oct-2017.pdf

[2] Green Climate Fund https://www.greenclimate.fund/statement/enhancing-access-and-increasing-impact-role-multilateral-climate-funds

[3] The Wellcome Trust https://wellcome.org/grant-funding/schemes/climate-impacts-awards

[4] Asian Development Bank https://www.adb.org/projects/51033-001/main

[5] World Bank https://www.worldbank.org/en/news/press-release/2024/05/31/world-bank-group-and-imf-deepen-joint-effort-to-scale-up-climate-action

[6] World Health Organization https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health

[7] ExpandNet https://expandnet.net/tools/

[8] Cash et al (editors) (2011) From One To Many: Scaling Up Health Programs in Low Income Countries World Health Organization & ExpandNet

[9] WHO (2011) Nine Steps for Developing a Scaling-up Strategy ExpandNet

[10] WHO (2011) Beginning With The End In Mind: Planning Pilot Projects And Other Programmatic Research For Successful Scaling Up ExpandNet

[11] Green Climate Fund (2023) GCF- SAP CREWS Scaling Up Framework For Early Warning www.greenclimate.fund

[12] United Nations Office for Disaster Risk Reduction https://www.undrr.org/implementing-sendai-framework/partners-and-stakeholders/multistakeholder-initiatives-and-partnerships