Crossing the Scale Barrier

December 4, 2013

Among the simpler approaches to strategic philanthropy — verging on the simplistic — is the venerable Demonstration Program. In the idea’s most basic form , a foundation supports a new activity in three to five places, “demonstrates” it, documents its successes (if there are any), and then publishes a report recommending that the model be “taken to scale” — i.e., copied everywhere.The experience usually ends with a handful of inspiring stories and (at best) some solid evidence that an idea worked well in limited circumstances. 
Yet even apart from the cost of expanding a new idea, this approach is loaded with problems. For starters, programs sometimes work wonderfully on a small scale precisely because they are implemented by a cadre of wonderful people, or at least by very highly motivated people who really “get” the idea, believe in it passionately, and fully embody the skills and personal traits that make it work best.
You can rally 20 of those kinds of great people to make a terrific demonstration in a few neighborhoods. Can you find 200 of them to carry it citywide? Could you marshal 2,000 or 5,000 to take it statewide? Even assuming you find them all, will they all implement the model consistently? And will supervisors and managers be able to ensure quality across a much larger landscape? The drag from these and other hurdles of growth are commonly known as the “scale penalty”: When programs leap from small demonstrations to much larger operations, they can expect to lose as much as half their quality and effectiveness along the way.
One promising new idea in family services, called nurse home visiting, has benefited from much more than the usual small-scale demonstration funding. There are by now several large organizations across the country that have developed and rigorously tested the model at considerable scale. Several have been proven to benefit the particular families that participate in them. But until now, none has been proven to work at anything like universal scale — serving all of the target population in a large jurisdiction and creating an overall effect that measurably improves conditions across the region
In a study just published, experts at Duke’s Center for Child and Family Policy have done such a test with Durham Connects, a “short-term, universal, inexpensive, … postnatal nurse home visiting program” in the university’s home county. Remarkably, according to Kenneth A. Dodge and his colleagues from the Center, Durham Connects has managed to overcome many of the constraints of the “scale penalty,” and has improved “population-level infant health care outcomes for the first 12 months of life” across the entirety of Durham County.
But it hasn’t been easy. In a separate publication, the researchers noted that Durham Connects spent a decade painstakingly building a network of some 400 family-service organizations across the county, so that its services could be coordinated with those of other agencies serving the same families. It has had to tailor its services to the widely varying needs of the thousands of families it serves, and subjected itself to a complex, demanding randomized-controlled trial, with a follow-up longitudinal study that lasted years.
None of that is typical — least of all the sustained funding that Durham Connects has received over the years from, among others, Durham County, the Duke Endowment, and Duke University. It has been a truly strategic endeavor, profoundly different from the short-term demonstration project typical in many other fields. And now, with the new evaluation results, Durham Connects has shown that the benefits of nurse home visiting really can be “scaled up,” with benefits that are neither cost-prohibitive nor limited to a narrow range of ideal circumstances.

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Tony Proscio

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Rip Rapson
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