Scaling up programs that have been shown to be effective in promoting health and other social causes in pilot and demonstration projects or larger efficacy and effectiveness trials should be a major focus of social marketers. I say 'should be' for while we talk about population-based or social change, the fact is that few evidence-based practices ever achieve the scale necessary to make their promise or vision reality for the thousands or millions of people who could benefit from them.
Though numerous examples abound to support this conclusion, I will focus on one: HIV prevention programs. The Global HIV Prevention Working Group has just released a report on the 'failure to scale' (my words, not theirs). Among their findings (excerpted from the Executive Summary):
Despite the extraordinary potential of available prevention strategies, most people at risk of HIV infection have little or no access to basic prevention tools. Although necessary coverage levels vary depending on national circumstances, current coverage levels for essential prevention strategies are woefully inadequate for any national epidemic.
- Condoms. Only 9% of risky sex acts worldwide are undertaken while using a condom, and the global supply of condoms is millions short of what is needed.
- HIV Testing. In the most heavily affected countries of sub-Saharan Africa, only 12% of men and 10% of women know their HIV status.
- Treatment for Sexually Transmitted Infections. It is estimated that fewer than 20% of people with a sexually transmitted infection are able to obtain treatment, even though untreated STIs increase the risk of HIV acquisition and transmission by several orders of magnitude.
- Prevention of Mother-to-Child Transmission. Years after clinical trials demonstrated that a brief, inexpensive antiretroviral regimen could reduce the risk of mother-to-child HIV transmission by 50% (5), only 11% of HIV-infected pregnant women in low- and middle-income countries receive antiretroviral prophylaxis.
- Prevention for Vulnerable Populations. Prevention services reach only 9% of men who have sex with men, 8% of injection drug users, and under 20% of sex workers.
- Prevention in Health Care Settings. An estimated 6 million units of unscreened blood are transfused yearly in developing countries, and 40% of injections administered in health care settings are unsafe.
Among the factors the Working Group identifies as fueling the failure to scale HIV prevention efforts are:
Inadequate Financing. While financing for HIV has increased dramatically in recent years, available funding is only slightly more than half of amounts needed to support a comprehensive, scaled-up response. In Asia, where the number of HIV infections could double in the next five years to more than 20 million, current spending on HIV/represents roughly 10% of the amounts needed to mount a comprehensive response.
Misallocation of Resources. In part due to the weakness of HIV information systems, many countries do not target limited funds where they would have the greatest impact. Misallocation of limited resources by donors and affected countries also often occurs as a result of ideological, non-scientific restrictions imposed by donors on how HIV prevention assistance may be used.
Capacity Limitations. Due to inadequate human capacity, countries often have difficulty programming substantial infusions of new funding.
Service Fragmentation. HIV prevention has frequently not been integrated into schools, workplaces, and other institutions, and HIV efforts are insufficiently linked with other health-related service systems, such as TB or sexual and reproductive health.
Stigma and Discrimination. The stigma associated with HIV and with membership in a vulnerable group deters many at-risk people from seeking HIV prevention services or learning their HIV status and also discourages the kind of political leadership required to implement a robust and evidence-based HIV prevention effort.
Our challenge, whether it be in HIV prevention or the prevention of childhood obesity, it to apply the evidence-base of diffusion research through social marketing programs. Several impediments stand in the way of doing so, not the least of which is the overwhelming (at least to me) lack of understanding among health professionals and policy makers of what this research offers health and social programs (other than fleeting references to The Tipping Point). The second is that very few social marketers seem to know how to transform programs focused on individual behavior change to ones scaled for population impact. Even fewer researchers and their funders seem to get that developing and testing programs meant to achieve scale need to be designed that way to begin with and not focused on reductionistic minutiae that - again - focuses on individuals, not people. And finally, as the Working Group makes clear, and as an old saying goes (thanks to Thomas Friedman): A vision without resources is just an hallucination.