Though hundreds of mHealth pilots have been developed, there is not a broad understanding of how to scale up mHealth projects. Scaling up mHealth was addressed by the November 19th meeting of the mHealth Working Group, including presentations on JSI’s cStock project in Malawi and UNICEF’s Programme Mwana in Zambia and Malawi. Scaling up mHealth for MNCH: Lessons from IWG Catalytic mHealth Grantees and Building Partnerships to Reach Scale are also being discussed at the 2013 mHealth Summit.
Scaling up generally means “more.” But more what? Scaling health services can bring more inputs (funds and staff), outputs (access to and range of services), quality, efficiency, outcomes (coverage or utilization) or impact (morbidity or mortality).  Scalability should be considered from the start of a mHealth project.  Various frameworks and overviews focus on mHealth scale up, each covering its own concepts. Summarized here are the key concepts in published frameworks and overviews for scaling up mHealth and health ICT. These topics are introduced by related concepts for scaling up global health projects. The concepts span organizational, technological and programmatic domains. Some concepts are less familiar than others. But the breadth of issues is best appreciated from a breadth of sources on mHealth scale up.
For health services, NGOs and government partners have important roles in scale up.  Health organizations should advocate for necessary changes in government policies. For mHealth frameworks, strategic leadership also affects the ensuing issues of goals, funding, standards and partnership.  Leadership can combine the perspective and influence of government, implementers and donors. Governments have a leading role in determining national policies and regulations for ICT.  Accordingly, JSI’s cStock project encouraged ministry of health ownership at every stage by fostering internal champions, formation of a scale up taskforce with a ministry chair, and building capacity of the ministry to lead. 
Alignment with Health Goals
For health services, scale up depends on the relevance of the proposed innovation.  In mHealth frameworks, this means aligning mHealth with the strategic goals and priority interventions of national and provincial health departments.  In scale up of health ICT, integration into the underlying healthcare system is important because “mHealth is not going to stand by itself.”  UNICEF’s Programme Mwana was designed to meet the larger needs of the health system and to not compete with others efforts.  For guidance on health service scale up, the scope is expanded since “narrow” scale-ups can obstruct the continuum of care.  Likewise, there is guidance for ICT scale up integrating primary care services to avoid disease-specific silos. 
Alignment with Partners
For health services, scale up should include a participatory process with key stakeholders.  For scale up in ICT4D, national ownership is defined, designed and delivered primarily by national stakeholders.  JSI’s cStock implements this with “partnering to scale” for joint ownership and capacity that endures past the end of a project.  Stakeholders range from national governments to local users. Programme Mwana was designed to fit users’ way of seeing a problem and solving their “pain-points. 
Alignment with mHealth partners also includes alignment with and between funding sources.  The “perpetual pilot syndrome” is often accompanied by a “competing pilots syndrome” where similar models developed by different donors do not aggregate into a large-scale resource.  UNICEF’s Programme Mwana asked funders to collaborate for mainstreaming mHealth rather than developing separate mHealth systems. 
Public-private partnerships are featured in ICT4D scale up guidance.  UNICEF’s Programme Mwana negotiated with all major telecom companies in Zambia to transmit on all networks and scale nationally.  There is great potential in public-private partnerships, but guidance on partnership for mHealth scale up advices that collaborating across sectors can present conflicts in organizational cultures and operational structures. 
Cultural and Institutional Context
For health services, scale up may require tailoring an innovation to socio-cultural and institutional settings.  Scaling health services can also be compatible with norms and values.  For scaling up health ICT, the contextual understanding can include local content creation, local language used, and content related to the local situation.  UNICEF’s Programme Mwana used a human-centered design process with Frog Design to ensure that software would make sense in the local context and be easier to adopt. 
Guidance on scaling health services suggests reducing the technical complexity of interventions.  Keeping the innovation simple fits the capacity of the implementing organization, or otherwise significant capacity strengthening is required.  For mHealth scale up, simple design may be necessitated by low levels of education, limited training costs, lack of resources, and lack of dedicated time to use the system.  As projects and partnerships scale, there can be increasing demand to expand the scope and complexity of a project. For mHealth, “these types of changes can have serious implications on the requirements.”  JSI’s cStock maintained simplicity by limiting the number of data items collected to what was really needed. 
When scaling international health interventions, usage characteristics relate to ease of use, with some interventions requiring more information or training.  Usability is a key factor in mHealth scale up.  Usability of a mHealth application includes ease of use, its errors, likeable design, and applicability to a wide breadth of end users.  Usability may relate to the mentioned issues of simplicity and demand.
For scaling health interventions, stability of the product is important.  In health ICT, this can depend on the reliability of an electrical power supply, phone transmission, the resources to pay related bills, and comfort with routine use.  The robustness of mHealth in a low resource environment relates to is ability to scale up in such a low resource environment.  Programme Mwana designed a robust system by including redundancies on core functionalities, as well as minimizing “dependencies” by utilizing user-owned phones. 
When scaling mHealth, flexibility relates to the ability to adapt improvements and innovation as organizational challenges and needs evolve. This includes flexibility to accommodate change, as well as flexibility to accomplish a range of tasks. 
Standards and Interoperability
For health interventions, scale up is influenced by the degree to which an intervention can be standardized.  For mHealth, standards and interoperability are key issues.   This can help different health ICT applications to be shared, replicated and scaled up. 
For health services, it is recommended to test an innovation in the variety of settings where it will be scaled up.  Testing should be conducted under routine operating conditions with existing resource constraints.  Beyond the intervention itself, it is important to assess and document the process by which intervention is implemented.  For scale up of health ICT, evaluation can allow corrective measures or indicate whether investment in ICT is worthwhile. 
For health services, plans should be made to promote learning and disseminate information. 
“Scaling up requires that a lot of people in a lot of places are well-informed about the relevant Interventions.”  In ICT4D, information-sharing can facilitate replication elsewhere.  For mHealth, a learning environment can promote collaboration and use a repository of evidence to inform decision making.  The replicable implementation processes should also be visible. 
For health services, scale up relies on management issues such as leadership, supervision, incentive structures, costs, financing, logistics and a management information system.  Scale up of NGO services can evolve through the phases of entrepreneurial initiative, task team, project implementation organization, and program institutions.  Sound management is also important for scale up of health ICT.  For example, JSI’s cStock project used district product availability teams to provide the project with enhanced management and a structured process for using the data collected through mobile phones to improve the system.  UNICEF’s Programme Mwana provided redundant management for key functions. 
For health services, capacity is required for the health system, organization, staff and users. For governments in particular, demands on scarce capacity can constrain the scale up of health interventions.  For scaling mHealth, implementation capacity includes organizational readiness and mechanisms for implementation, support, monitoring and evaluation.  Health ICT can also require ICT literacy for health workers that lack training or experience.  Capacity may relate to the simplicity of mHealth, as well as the strategic leadership mentioned above.
Pace of Scale Up
Scaling up health services can occur in a smooth incremental process, a series of steps, or rapid leaps.  For mHealth scale up, there is a similar choice between quick Iterations of development versus building for scale. Quick development for field testing allows a lightweight solution, while software built for scale requires investment in a system backbone. 
For health services, scale up is influenced by demand for an intervention at the political, provider and client levels.  Constraints to scaling up health services can stem from lack of demand or physical, financial or social barriers that limit their use.  For mHealth scale up, it is important to educate and engage end users and target beneficiaries throughout mHealth development to encourage buy-in.  This can extend beyond demand for the device or mobile service to include fostering a culture of information use. 
Cost and Cost Effectiveness
Cost and cost effectiveness are important issues for scaling mHealth.  There are high costs of hardware, software, telephone connections and Internet service providers in low- and middle-income countries.  Stakeholders could join together to negotiate lower rates from telecom providers.  Open source software is another option to reduce development costs.  Programme Mwana used open source software to avoid licensing fees and allow replication in in other countries.  JSI’s cStock project reduced costs by designing a system that was compatible with user’s own phones so that phones did not need to be provided.  It is important to calculate scale up costs to avoid surprises. 
Other issues introduced by frameworks and overviews for mHealth scale up. Privacy and security  can be important issues for risk management. Challenges differ when scaling across countries versus within a country, of course.  Scale up is clearly a multidimensional effort that can require a range of skills or partners. It is hoped that a broader understanding of these issues can enable collaboration for systems supporting impact on a national scale.
 “Scaling Up Health Services: Challenges and Choices,” WHO Technical Brief, p. 19, 12 June 2008.
 M. Noel, “cStock: A sustainable approach to using mHealth to support the community health supply chain,” in mHealth Working Group presentation, Arlington, 2013.
 K. S. Mate, G. Ngubane and P. M. Barker, “A quality improvement model for the rapid scale-up of a program to prevent mother-to-child HIV transmission in South Africa,” Internationa Journal for Quality in Health Care, vol. 25, no. 4, pp. 373-80, 2013.
 S. H. D. E. Leon N, “Applying a framework for assessing the health system challenges to scaling up mHealth in South Africa,” BMC Medical Informatics and Decision Making, vol. 12, no. 123, 2012.
 W. Gerber, “The Use of Information and Communication Technology in Family Planning, Reproductive Health, and Other Health Programs: A Review of Trends and Evidence,” Management Sciences for Health, Arlington, 2011.
 R. Simmons, P. Fajans and L. Ghiron, “Beginning with the end in mind: Planning pilot projects and other programmatic research for successful scaling up,” WHO, Geneva, 2011.
 S. Hughes, “Community Multimedia Centre Scale-Up – Opportunities and Challenges,” UNESCO, Paris, 2004.
 M. Schaefer, “Programme Mwana,” mHealth Working Group presentation, Arlington, 2013.
 M. Schaefer, “Designing mHealth Programs with Scale in Mind,” Stanford Social Innovation Review, vol. February 20, 2013.
 J. Lemaire, “Developing mHealth Partnerships for Scale,” Advanced Development for Africa, Geneva, 2013.
 C. Gericke, C. Kurowski, K. Ranson and A. Mills, “Intervention complexity — a conceptual framework to inform priority-setting in health,” Bulletin of the World Health Organization, vol. 83, no. 4, April 2005.
 R. Luk and E. Bancroft, “ICTs for Supply Chain Management in Low-Resource Settings,” Village Reach, Dimagi, Boston, Seattle, 2013.
 L. Mangham and K. Hanson, “Scaling up in international health: what are the key issues?,” Health Policy and Planning, vol. 25, no. 2, pp. 85-96, 2009.
 T. Sanner, L. Roland and K. Bras, “From pilot to scale: Towards an mHealth typology for low-resource contexts,” Health Policy and Technology.
 P. Fajans, L. Ghiron, R. Kohl and R. Simmons, “20 Questions for Developing a Scaling Up Case Study,” Expandnet, 2007.
 P. Uvin, D. Brown and P. Jain, “Scaling Up NGO Programs in India: Strategies and Debates,” Institute for Development Research, Boston, 2000.
 E. Futrell and M. Puleio, “The mHealth Planning Guide: Key Considerations for Integrating Mobile Technology into Health Programs,” K4Health, Baltimore, 2013.