What is needed for taking emergency obstetric and neonatal programmes to scale?

- Scale-up is a non-linear change process at different levels of the health system.
- For scale-up, multiple strategies requiring simultaneous attention must be deployed.
- Equity, quality and leadership cut across all programme components.
- A positive policy environment and system strengthening are essential for scale-up.
- Other important conditions relate to resources, training, supervision and monitoring.

Scaling up an emergency obstetric and neonatal care (EmONC) programme entails reaching a larger number of people in a potentially broader geographical area. Multiple strategies requiring simultaneous attention should be deployed. This paper provides a framework for understanding the implementation, scale-up and sustainability of such programmes. We reviewed the existing literature and drew on our experience in scaling up the Essential Steps in the Management of Obstetric Emergencies (ESMOE) programme in South Africa. We explore the non-linear change process and conditions to be met for taking an existing EmONC programme to scale. Important concepts cutting across all components of a programme are equity, quality and leadership. Conditions to be met include appropriate awareness across the board and a policy environment that leads to the following: commitment, health systems-strengthening actions, allocation of resources (human, financial and capital/material), dissemination and training, supportive supervision and monitoring and evaluation.