Scaling Up Whole Child Development Initiatives: Lessons from the Early Journey of Life Program in Vietnam

Abstract

Human development programs—for example, early childhood interventions—often depend on high-quality, respectful human relationships. This creates a challenge for implementation at large scale. Here, we review how this challenge was addressed in the scale-up of the Early Journey of Life (EJOL) program, an evidence-based initiative in Vietnam that supports parents and families in the first 1,000 days of children’s lives. The program’s experience highlights the value of an approach to scaling that aims to energize stakeholders, including at the front line as well as among government leaders; rapidly learn and adapt based on new evidence; empower leadership across the delivery system; rebalance agency to the front line; and gradually but systematically embed program principles and activities in large government systems. Our findings suggest that EJOL’s work to implement scale-up along these lines was in turn grounded in high-quality relationships with those engaged in the program, from family members to frontline workers to middle managers and senior government officials. The EJOL program has successfully scaled to reach 109 rural communes in Ha Nam province and continues to expand and diversify while retaining its core focus on high-quality human relationships.

Worldwide, about 250 million young children are at risk of disruptions to their development because of undernutrition, poverty, and other adverse conditions (Lu et al., 2016). In low- and middle-income countries, a variety of interventions that support parents and parent–child relationships have proven effective at protecting children from this risk (Advancing Early Childhood Development, 2016). However, such interventions, with their emphasis on high-quality human relationships, have generally been challenging to implement at large scale, such as to reach a substantial portion of the at-risk population in a province or other major jurisdiction (List et al., 2021; Radner et al., 2018). For example, a recent trial designed to test large-scale implementation of an evidence-based home visiting program in India and Pakistan “did not achieve significant impacts” (Hill et al., 2023, p. 2). To understand why, the researchers conducted a process evaluation and identified problems in visit quality; in recruiting, training, coaching, and supervising frontline workers; and in dealing with time pressures facing both service providers and families. These barriers to scaling are recognized in the broader literature as well (Cavallera et al., 2018; Hartmann & Linn, 2008; List et al., 2021).

Background on Implementing at Scale

Recognizing the importance of the scaling challenge, early childhood researchers and implementation scientists have emphasized the value of reporting on and analyzing approaches to implementation at scale in early childhood programming (Aboud & Yousafzai, 2019; Aboud et al., 2018; Britto et al., 2018; Cavallera et al., 2018; Fisher et al., 2020, 2022; List et al., 2021; Richter et al., 2016; Yousafzai et al., 2018). In parallel, researchers and practitioners working on scaling up public health and human development programs more generally have developed a series of valuable comprehensive frameworks for scaling up (Cooley, 2016; Informing Design, 2019; Hartmann & Linn, 2008; Kohl & Linn, 2021; Kumar et al., 2015; Lawrence et al., 2020; Lombardi, 2016; Metz et al., 2015; Simmons & Shiffman, 2007; Simmons et al., 2007). Here, to complement and enrich these strands of research, we offer a qualitative review of the transition to scale strategy of the Early Journey of Life (EJOL) initiative in Vietnam.

An overarching insight from the implementation literature is that scaling is a complex, cross-disciplinary process:

[S]caling up is multidimensional, involving not only technology transfer and the dissemination of information. It is a more complex social, political and institutional process than was recognized earlier. Occurring within a web of interacting forces, going to scale must engage multiple actors, interest groups and organizations, while taking account of the larger socioeconomic, political, cultural and institutional contexts within which it takes place. (Simmons et al., 2007, p. x¹).

Simmons et al. (2007) offer a set of principles for addressing challenges this process entails, ranging from grounding the work in core values to fostering broad stakeholder engagement, community involvement, learning, and adaptation, to conducting research on the scaling process itself. They also emphasize the importance of planning for scaling early on, including before and during what is traditionally thought of as the pilot phase.

These ideas resonate with the work of other authors. Cooley (2016) provides a detailed, practical framework for scaling, with action steps in stages. This framework entails substantial attention to early planning and then to laying the groundwork for success. Wide stakeholder engagement, adaptation to context, attention to organizational dynamics, coordination across actors, and ongoing, sustained collaboration are prominent features of the later stages in the framework.

Similarly, Kohl and Linn (2021) offer a comprehensive set of 20 lessons on effective scaling, organized around eight principles and beginning in the planning stages. Kohl and Linn address dimensions of scaling including creating an inclusive vision; identifying core, scalable intervention components; identifying all stakeholders relevant to scaled implementation; and planning for system change. Their final three principles are particularly relevant to the present study, since they are a good fit with the scaling phase examined in here—the transition to scale, as opposed, for example, to planning phases:

Principle #6: Create demand and mobilize resources for the scaling initiative by aligning incentives and pursuing advocacy to change attitudes, mindsets and social norms and enlist stakeholders….

Principle #7: Iterate, learn, adapt and sustain the scaling pathway as long as needed….

Principle #8: Base all scaling decisions on relevant evidence and continuous learning. (Kohl & Linn, 2021, pp. 3–4)²

Consistent with these ideas, but with a focus on the unfortunate empirical pattern that early childhood programs with successful pilots have experienced reduction or loss of impact as they scale, List et al. (2021) synthesize that experience by providing an economic model incorporating specific threats to a simple “pilot and scale” strategy. The threats include challenges with statistical inference, diversity in population, diversity in situation and setting, and spillover and general equilibrium effects. With a combination of theoretical analysis and practical case studies, List et al. (2021) offer research strategies to build knowledge in a way that can address each of these challenges.

The Early Journey of Life Program

The recent experience of the EJOL³ program in Ha Nam province, Vietnam, provides an example of transition to scale in early childhood development that has met, thus far, with promising success. EJOL is a parenting education program for new mothers and their families. Drawing on international evidence-based parenting curricula, the program covers a wide range of topics, from healthy pregnancy to prevention of gender-based violence to child health and development. Local facilitators deliver the curriculum in 20 sessions, mostly in groups at community centres (Fig. 1).⁴

Fig. 1

EJOL Community Practice Session. Note. Photo credit: Hoang Kim Dung

After conducting formative research on risk factors affecting pregnant mothers and families with young children in Ha Nam province, EJOL and its government partners designed and piloted an early version of the program in 2013 (Fisher et al., 2011, 2010, 2013a, 2013b; Hanieh et al., 2013). Encouraged by the results of the pilot, they began their transition to scale in 2014. They delivered the program to 918 participants in Ha Nam and tracked implementation, with attention to the benefits families were deriving and a focus on acceptability, fidelity, and alignment with the program’s purpose and context. Results were promising, so the team then developed and implemented a parallel-group cluster randomized control trial that concluded in 2020. The trial assigned 1,245 women, again in Ha Nam province, into treatment and control groups; the results established the program’s effectiveness (Baek et al., 2023; Fisher et al., 2018, 2023).

After the completion of the trial in 2020, EJOL continued its transition to scale in collaboration with the Provincial Centre for Disease Control, which took on implementation responsibility, with EJOL’s support. Through this collaboration, stakeholders in Ha Nam province are currently operating the program in all of the province’s 109 communes. From 2021 to 2022, the program served 29,866 women in pregnancy or with children under two years of age, accounting for about 60% of the target population in the province.⁵ EJOL is continuing its scaling work, with plans to expand beyond Ha Nam and to complement its in-person model with digital delivery.

Purpose and Approach of Our Work

Our purpose here was to work with EJOL’s senior leadership to understand and reflect on the approach they had been taking to achieve their early transition-to-scale success and to derive lessons that could inform ongoing and future efforts. Given this focus on evolving strategy, we used a developmental evaluation approach to our inquiry.⁶ We and our colleagues had previously synthesized five themes from other transition-to-scale efforts we had observed where high-quality, respectful relationships with families were maintained as programs sought to make the transition to scale. These themes involved (1) engaging stakeholders; (2) monitoring, evaluation, and learning; (3) enabling leadership; (4) empowering people at the front line; and (5) embedding programs in government systems for the long term (Barth et al., 2023; please see Online Resource 1 for a summary of the five themes). We conducted a structured dialogue with EJOL leaders with the goal of comparing EJOL’s scaling strategy with these approaches. This comparison revealed substantial resonance, but also uncovered distinctive features of the methods EJOL had used in relation to each of our themes.

By “transition to scale,” we mean passage beyond initial, small-scale piloting (perhaps reaching several hundred people) to larger trials (reaching over 500 people) and early expansion beyond that (perhaps reaching thousands or tens of thousands). Reaching and sustaining nationwide coverage would typically follow this transitional phase. Our focus here was on EJOL’s transition. We aim to extract lessons from that phase of EJOL’s development; our findings therefore address topics relevant to that phase rather than to the entire range of challenges identified in the literature for the full scaling journey.

In the rest of this paper, we first describe the developmental evaluation methodology we used. We then present our results, organized (in subsections) around the five numbered themes outlined above, to bring out the fruits of comparing EJOL’s experience with our previously developed thematic framework (Barth et al., 2023, summarized in Online Resource 1). The discussion that follows offers some overall reflections on those results and places them in the context of the scaling up literature described above and of scaling experiences reported elsewhere. We conclude with a summary of key lessons, in the context of recommendations for implementers and implementation researchers.

Methods

The purpose of our inquiry was to assess the already at least partially successful transition-to-scale strategy adopted by EJOL from the point of view of the senior leaders who set that strategy and to compare their perspectives with the thematic framework we had developed from work with a wide variety of other early childhood programs that were generally at earlier stages of scaling (Barth et al., 2023). EJOL had already reported encouraging results in its transition to scale (Fisher et al., 2023); we did not seek to assess the program or its results. Instead, we hoped to harvest lessons emerging from EJOL’s ongoing, evolving work in a way that could inform EJOL’s development and might also hold promise for broader application. We selected developmental evaluation for our inquiry design, since that approach is tailored to rapidly eliciting usable lessons while program activity is evolving. The comparison with perspectives derived from other programs provided a way to set up what we hoped would be a productive reflective interchange, a common goal in developmental evaluation.⁷

We carried out our developmental evaluation within the narrative inquiry tradition of qualitative research and evaluation (Bruner, 1991). In this spirit, we sought to understand the experiences and perspectives of the EJOL leaders who developed and implemented their transition to scale strategy. As further detailed below, we used qualitative deductive analysis (Patton, 2014) to code and interpret our data: JR carried out the deductive coding and thematic analysis, and PG separately reviewed the data to identify examples and comments as they related to the framework in Barth et al. (2023). The authors then combined and refined their results and used respondent validation (Pope & Mays, 2006) to further hone the findings and enhance confidence in them.

Since the developmental evaluation aimed to understand, in the context of an emerging thematic framework (Barth et al., 2023), the perspectives of EJOL’s senior decision makers on their own scaling strategy, we selected as interviewees the two leaders who were setting that strategy, and who had done so from program inception: Ms. Ha T. T. Tran, Executive Director of the Research and Training Center for Community Development, which developed and implemented EJOL; and Prof. Jane Fisher of Monash University, who designed and led formative and impact research associated with the project. We understood that these two senior leaders jointly made the major strategic decisions involving EJOL as a whole, including its approach to scaling.⁸

This inquiry strategy allowed us to set up an interplay between the perspectives of Ms. Tran and Prof. Fisher, the team that had led a program into an effective transition to scale, and perspectives drawn from other scaling efforts (summarized in Online Resource 1 and described in more detail in Barth et al., 2023). The comparison provided a modest degree of mutual validation, but also, perhaps more importantly, it promised enhanced understanding of transition-to-scale strategy beyond what either set of perspectives could provide alone.

In sum, this was a key informant interview strategy that intentionally focused on the views and narrated experiences of EJOL’s two senior leaders. They therefore precisely constituted the universe for selection of interviewees. Upon interviewing both, then, we considered that we had reached sample saturation. To ensure substantive significance (data sufficiency), we conducted the interviews in an open-ended fashion and stayed with each topic until our respondents were finished expressing their views. In that spirit, we offered opportunities for the respondents to provide additional observations or perspectives and to revisit earlier topics in the interview sequence before we closed. We also invited the respondents to comment by e-mail on our findings. As it turned out, we needed a roughly 50% increase from the originally planned time for the interviews.

Developmental evaluation involves collaboration between researchers and program managers to reflect on strategy and experiences.⁹ We took that approach here, so we began by reaching out to the two EJOL leaders (initially by e-mail) and discussing, in a Zoom video session with both respondents, our proposal to work with them as described here. They were enthusiastic and exchanged ideas with us throughout the inquiry. Earlier joint work had created relationships which grounded the collaboration described here: Two of us (JR and JL) had worked with Ms. Tran and Prof. Fisher when we facilitated a series of workshops sponsored by Grand Challenges Canada (GCC) and its grantees, including EJOL. Based on these observations, we believed Ms. Tran and Prof. Fisher could readily speak freely around each other, and we concluded that the best way to generate productive reflection with them was to interview them jointly. In this manner, the ideas of each could build on the other’s, in the spirit of a developmental evaluation reflective practice session.¹⁰

After reaching agreement with the two EJOL leaders on the process for our inquiry, we first requested and reviewed a range of resources about EJOL, including published reports and materials that had been distributed in a more limited way, for example to donors and conference attendees. (These latter of resources included slide presentations and a recorded webinar session, in addition to written documents.) For an inventory of these materials, please see Online Resource 2. We undertook the materials review primarily as background for our interviews, so that we could knowledgeably probe for insights during our interviews. The documents and related resources provided us with a good general picture of EJOL’s history, its programming, and its achievements in the transition to scale.

Having completed the document review, we designed and held a series of semi-structured interviews with the two EJOL leaders participating together that were at the heart of the developmental evaluation. Since we hoped to encourage reflection by the EJOL team on their own strategy and experiences, we took an appreciative inquiry¹¹ approach to the interview process. Our goal was to compare EJOL’s approach and perspectives with the themes outlined in Barth et al. (2023); we used those themes as a framework for the interview guide and as researcher-supplied sensitizing concepts¹² for the interviews. We sent our interviewees a near-final draft of Barth et al. (2023) in advance, along with a copy of the interview guide. The guide quoted the summary of each major theme from the paper and asked a common set of questions in relation to each theme in turn, as a way to assess the potential application—or lack of application—of these themes to EJOL’s experience and strategy. Please see Online Resource 3 for a copy of the guide.

We planned two one-hour interviews, each with Ms. Tran and Prof. Fisher together, to work through the interview guide. As noted above, however, we paced the interviews flexibly, to enable the respondents to provide their full perspectives on each topic. This required extending the interview series to three. Two of us (PG and JR) jointly conducted the interviews on Zoom video sessions. With the interviewees’ permission, we used the Zoom system to obtain a recording of each interview and produced automated transcripts via Zoom and Temi.

Since we had, by design, provided in advance a thematic structure for the inquiry, our content analysis was not primarily based on inductive coding to generate themes. Rather, we carried out a qualitative deductive analysis. In accordance with that methodology (Patton, 2014), JR reviewed the transcripts and marked the hard copies, both to classify comments by the major researcher-set themes¹³ and to identify and code new, subsidiary, or cross-cutting topics emerging from the responses. These topics often reached beyond points made in the original framework (Barth et al., 2023). Note that the findings reported below are presented sequentially, based first on the five original themes and second on identified additional topics.

PG also reviewed the transcripts, major theme by major theme, to identify portions of the responses that together best represented the perspectives of the interviewees on the theme in question. Both PG and JR also looked for specific examples or reported experiences that brought out those perspectives. We combined our results, yielding material both of us had identified.

We then drafted a bullet-point summary of these combined results and shared it with our respondents for comment. We incorporated their feedback (provided largely by e-mail, but also during the sequence of Zoom sessions) in revised summaries that we also shared for comment with the respondents. This process largely preserved the originally identified points, but it also led to some additions and revisions. Later, we sent drafts of the present paper to the respondents; we again obtained their written comments by e-mail and also received feedback in a follow-up Zoom session. We refined our findings through further exchanges of e-mails, including asking the respondents at times to elaborate on specific points made during the interviews. This collaborative approach was designed to elicit insights with the two EJOL leaders via the “rapid feedback interviews” method in developmental evaluation¹⁴; it also enabled us to secure respondent validation for our findings.¹⁵

To complement the analytical approach described above, the three authors reviewed the transcripts to identify quotations that illustrated the overall point of view of the respondents for each theme. We shared both the transcripts and the selected quotations with the respondents and welcomed their comments and corrections. Our transcript reviews were also aided by notes prepared by PG that outlined interviewees’ responses.

Note that we did not have an opportunity to pilot our very specific interview guide. However, since we conducted a series of three interviews with the same respondents, and since the basic questions in the guide were repeated for each theme, we did have a chance both to refine our interview approach—by increasing the time for informal reflection—and to allow the respondents to clarify or build on their earlier replies.

The two EJOL leaders participated as colleagues in the developmental evaluation and granted permission to use in this article all data they supplied (oral and written), and to include all the quotations presented below, with attributions. Further ethical considerations are set out below in the ethics declaration.

Results

EJOL’s Experiences Through the Lens of Theme 1: Engaging Stakeholders

EJOL bases its scaling approach on active engagement with stakeholders at the family, commune, provincial, national, and international levels in a way that aligns everyone’s interests and expertise to advance a common agenda. Ms. Tran emphasized the importance of EJOL’s stakeholder work for scaling:

Only when this theme, this area has been invested in, only because we invested in the effort of partnership building, we were able to go to further stages of development, from local service delivery to initial scale solutions and scale-up in the future.

In the phased approach described by the two EJOL leaders, the first step was to focus on family needs, identified through local consultations and formative research. On this basis, EJOL developed a curriculum with three major focal areas: health, child development, and women’s empowerment. EJOL then chose three local service cadres who were already active in Ha Nam province, corresponding to these three curricular areas: community health workers, engaged by the provincial Department of Health; kindergarten teachers, engaged by the provincial Department of Education and Training; and women’s coordinators, engaged by the provincial Women’s Union.

The EJOL team connected with these service cadres locally, to create a three-part, community-based service delivery model. The two leaders highlighted to us how EJOL invested in good community-level relationships (discussed in more detail under Theme 4 below) to ensure that local providers were motivated and supported. They also discussed the purposes of the program with community leaders, supported them in selecting the three local service providers in each community—a health worker, a teacher, and a women’s coordinator—and worked to “harmonize” (as Ms. Tran put it) this trio into an effective delivery team. The selection process aimed to identify local service providers who had already demonstrated commitment to the community.

With this local structure in mind, EJOL invested in building relationships with leaders of all three relevant provincial agencies so the local model they were building could be scaled. Looking ahead, they also engaged with national and international agencies, such as the national Ministry of Health and, internationally, the Vietnam offices of the World Health Organization and UNICEF.

As a current example of national relationship-building for future scaling, EJOL cited their work with the Vietnam General Confederation of Labour to include around 1,000 industrial young workers in two provinces in 2022 (Early Journey of Life, 2023). EJOL regards this as a significant scaling opportunity, because, as the EJOL team notes, there are 5.9 million young industrial young workers in Vietnam, 70% of them with young children.

To explain their success in building and maintaining relationships with provincial and national agencies, the two EJOL leaders pointed to the way they worked to (1) understand agency leaders’ goals and to align their program with those goals; (2) share information about EJOL’s activities and interim results openly and freely; and (3) build productive personal relationships with more and more people in partner agencies. As our respondents put it:

• (1) We were able to understand what their own goals were, their own performance indicators, and how we could assist them to realize those through our program. (Prof. Fisher) We always ask: What program in the area of maternal and childcare and support are you working on right now? What kind of policy are you working with, and how can Early Journey of Life support you to fulfill that? ... That is how they give us a road map of how to integrate EJOL into the national program and how to align with the government’s program. (Ms. Tran)

• (2) Information sharing … is the best way to have them on board as an insider. So we don’t wait until the end of the project to inform them, but during project implementation we update them frequently. This is very important. (Ms. Tran) We have a strong principle of transparency. We know that trust is easily corroded, and so we ensure that we speak truthfully and transparently, and we really seek to live what we promise. (Prof. Fisher)

• (3) We always question ourselves: Who else do we need to involve, to make aware of the innovation? Who else do we need to strengthen our partnership between them and us in order to make the innovation work better? Who else that we never think of? (Ms. Tran).

Finally, as a practical tool for their stakeholder work, the two EJOL leaders cited the value of a mapping exercise they undertook. They listed their stakeholders, at both the local unit level and the transition to scale level; created a map which showed relationships among them; and recorded, specifically, the value each stakeholder received and contributed in those relationships. This helped EJOL “make sure that all the stakeholders experience success or experience a benefit” (Prof. Fisher).

Overall, then, the two leaders understood that their transition to scale depended on a combination of strong local relationships, which were needed to create delivery units that could respond to family priorities, and equally strong relationships with provincial agencies that could support expanded delivery. They therefore worked systematically to build both those relationships in a way that benefited each stakeholder.

EJOL’s Experiences Through the Lens of Theme 2: Monitoring, Evaluation, and Learning

Rigorous research and systematic program monitoring have been at the heart of EJOL’s design and implementation from the program’s origins. EJOL’s leadership identified both research and monitoring as major ongoing commitments that have been important to their scaling strategy.

Research conducted in accordance with international standards has included prevalence studies of risk factors that contributed to program design and randomized control trials to evaluate program efficacy and effectiveness (Baek et al., 2023; Fisher et al., 2010, 2011, 2018, 2023, 2013a, 2013b; Hanieh et al., 2013). These studies have been important in many ways, but in particular for EJOL’s transition to scale, since evidence at a publishable level of rigor, covering both risk factors and program impact, was important to the government partners who would play a vital role in the EJOL’s scaling. The two EJOL leaders recalled how they shared their research with government stakeholders and saw the value of “doing it rigorously and thoroughly, to publishable standard” (Prof. Fisher) to support a multiyear process of “bringing the program from a single, local project into a national program” (Ms. Tran). Indeed, in a recent meeting with EJOL, officials from the national Ministry of Health requested additional randomized control trials to underpin national uptake.

All this research has been conducted through EJOL’s longstanding collaboration with Monash University. Looking ahead, the two leaders envision using new delivery models, incorporating digital delivery to enable cost-effective scaling. These models will require rigorous testing before large-scale implementation, both to establish efficacy and to more comprehensively understand the way the program’s components work.

As Hill et al. (2023) found, human resource management and quality assurance can be important challenges for scaled delivery of early childhood programming.¹⁶ EJOL worked with experts at Monash University to develop a data-rich monitoring, feedback, and supervision system to support high-quality delivery in their transition to scale. The system is fully digitized; it tracks details of in-person program delivery in each commune, with a combination of subjective (personal assessment) and objective measurements. The EJOL team regularly reviews the data and classifies local delivery areas as needing frequent, less frequent, or infrequent site visits to resolve problems and assure quality and reach. The two EJOL leaders elaborated on their constructive approach to feedback at the front line in their comments on Theme 4, below.

In addition to this supervisory and quality assurance function, EJOL also uses its data system to continuously improve the implementation. Ms. Tran emphasized that a key to this “very important” ongoing learning process was frequent data analysis and rapid response, “not quarterly, [but] monthly,” enabling the team to “adapt very quickly and make decisions for adjustment immediately.”

EJOL’s commitment to robust program monitoring also extends to its digital learning package, which it is now piloting as a complement to its in-person model. The EJOL team monitors progress and completion rates of digital learners through pre- and post-testing embedded in the digital modules; learners’ satisfaction is assessed through rating and commenting functions.

During our interview sessions, the EJOL leaders’ reflections on this theme also brought out an important challenge. Looking ahead to national, population-level scaling, EJOL aims to continue building domestic capacity for rigorous ongoing evaluation in accordance with international standards. EJOL also aims to work with the national government to adopt high-quality national early childhood development indicators. However, many funders prefer supporting implementation rather than research or research capacity-building. The ongoing challenge, then, is to align funding with EJOL’s (and the government’s) research priorities. However that challenge may be addressed, it remains clear that using research and data for evaluation, monitoring, and program improvement has been a central driver of EJOL’s transition to scale, enabled by the program’s sustained partnership with Monash University.

EJOL’s Experiences Through the Lens of Theme 3: Enabling Leadership

EJOL identifies, encourages, and enables leaders across its stakeholder network. It does this by aligning EJOL’s goals with the leaders’, developing good understanding of the program, and sharing information about operations, outcomes, learning, and plans. Ms. Tran saw information sharing as “very important.” EJOL’s high level of transparency, emphasized in the discussion of Theme 1 above as well, ensures that stakeholders have sufficient information to make their own decisions. They can accordingly act as leaders—e.g., by making changes in the field—to advance what they regard as a shared agenda. EJOL’s transparent approach also enables trust¹⁷ within what became, on transition to scale, a complex delivery system. Prof. Fisher regarded as “absolutely essential” the way Ms. Tran ensures that “everybody understands all, all the things they need to know about what’s been done, what we are learning, and what we are doing with that information, so that nobody’s left feeling there are secrets, there’s no form of manipulation.”

At the provincial level, EJOL identified champions¹⁸ for the program in each of the three agencies engaged in the transition to scale: the Department of Health, the Department of Education, and the Women’s Union. Ms. Tran called these three champions “heroes”:

We learned from experience that only when a project has a hero who can champion it will it go successfully. Even if it had been integrated into the agency action plan, without a hero with a passion for action it cannot succeed. That is why during the feasibility study and transition to scale we identified three heroes from Ha Nam province, one from [each agency].

Ms. Tran went on to individually describe and enthusiastically praise each of the heroes and their roles in the transition to scale. It became clear from her descriptions that, for EJOL, engaging provincial agencies for the transition to scale involved more than applying evidence and aligning policy with agencies viewed in the abstract; it also entailed connecting with the passions of individual people within the agency who could play the role of program champion.

EJOL’s Experiences Through the Lens of Theme 4: Empowering People at the Front Line

Recruiting and managing frontline workers is a key scaling challenge (Cavallera et al., 2018; Hartmann & Linn, 2008; Hill et al., 2023; List et al., 2021). EJOL lets its local, commune-level partners recommend “facilitators”—the frontline workers who implement the program—based on their commitment to the community. EJOL then provides the facilitators with training and support aimed at enhancing local capabilities. The EJOL team emphasized that their training is organized to build the confidence of local facilitators and provide skills to enable them to act as community leaders. When trainees seem insecure, for example about public speaking, trainers go out of their way to point out and reinforce strengths. EJOL’s management closely follows facilitators in the early stages of their work but extends increasing independence to facilitators as their capabilities grow, to the point where, in most cases, management involvement is no longer needed. EJOL has seen facilitators who have completed this process take an interest in community change and champion the EJOL intervention as a pathway to such change.

Feedback to the facilitators is central in EJOL’s training and supervision system. EJOL emphasizes appreciation, encouragement, and recognition, highlighting improvements rather than weaknesses (cf. Aguinis et al., 2012):

We encourage the frontline workers, the community-based facilitators, to work with the family. We enrich them, equip them with knowledge, and use an encouragement mechanism—a prize and a letter of appreciation. Every month we select the best performance of the month. We pave the road and appreciate what they have done and encourage them to work better…. If we see any issues, something that does not work well, we provide feedback to them, in a way that they feel comfortable with. (Ms. Tran)

As noted in the discussion of Theme 2 above, EJOL’s monitoring systems yield a rich flow of information about ongoing operations. EJOL’s ability to systematically share this information with frontline stakeholders gives substance to its transparent approach and enables constructive feedback:

I need to emphasize evidence-based appreciation. We not only say “You are doing well,” but also we provide them updated data, and [say] which community is the champion. They can see their improvement from month to month. And we say, ‘Wow, this month we did much better than three months ago.’ Every facilitator feels it; they can see that their efforts work. (Ms. Tran)

Finally, Hill et al. (2023) found that fitting early childhood programming into the busy schedules of frontline workers and families was a significant challenge to scaling. EJOL’s approach to implementing its transition to scale included continuous improvement in the effort to lighten the workload of frontline workers and align the programming with people’s schedules. By working closely with local partners during implementation, EJOL seeks ways to “improve service delivery, that will be closely in line with their daily work, to increase the sustainability and scalability and to make less work, in a way that will bring similar benefit to the family” (Ms. Tran). As Ms. Tran then described, for the current phase of the transition to scale EJOL was able to reorganize delivery into smaller 30-min sessions integrated with monthly health visits, thereby easing the time burden on workers and families.

In sum, EJOL has developed an approach to scaling challenges in recruitment, training, and human resource management that consistently supports and encourages frontline workers in their role in their communities, responds to constraints workers and families face, and makes it clear that people on the front line are valued.

EJOL’s Experiences Through the Lens of Theme 5: Embedding Programs in Government Systems for the Long Term

The two EJOL leaders stressed that they see their scaling journey as a long-term, living process. In particular, sustained engagement with the government—at the national, provincial, and local levels—is central to EJOL’s transition to scale and future expansion:

For a partnership to work so well and so productively, I don’t think we’ve ever said we’ll only work together for a year, or we’ll work until the end of a project. It’s been a commitment to knowing that this is a complex problem requiring a long-term relationship. (Prof. Fisher)

Embedding EJOL in government systems has been a phased process with different levels of government. EJOL began by engaging with local community leaders to develop and deliver its curriculum in three communes in Ha Nam province. The transition to scale started with an expansion to 42 communes, supported by EJOL’s successful engagement with the provincial Departments of Health and Education and the Women’s Union. For the next step in the transition, expansion to the whole province (109 communes), EJOL transferred implementation responsibility to a single government agency, the Provincial Centre for Disease Control. This agency has integrated EJOL into its existing immunization program, where monthly EJOL sessions are provided to pregnant women and families on immunization days. At each commune health clinic, health workers administer vaccines for groups of about 20 people (for example, pregnant women or children of specific ages) at specific times during two immunization days each month. There is then a 30-min post-injection waiting period, and that is when the health workers provide EJOL content to groups of mothers. Each mother receives about a dozen EJOL sessions this way; these are supplemented by online delivery. The current objective is to provide parenting education to over 33,000 pregnant women and parents with children from birth to age two in Ha Nam; under this model, every year around 11,200 newborns will benefit from the EJOL program via their parent’s learning.

These phased transitions across government agencies were possible because EJOL avoided rigid attachment to a single delivery model. Rather, as the shift to the “immunization day” delivery model illustrates, they collaborated with government agencies to solve the underlying policy challenge—supporting child development—in ways that worked for that agency. Ms. Tran described this shift as moving from a project focus to a focus on an agency’s “program” and “policy mandate”:

Now [at this stage of the transition to scale], it goes beyond the project perspective. It is the program. It is a [policy] mandate about improved maternal and child health, improved early child development service in Vietnam, to enable all the children to have the right to reach their full potential of development. So that is our mandate now.

As they work to extend the transition from provincial to national scale, EJOL’s leaders have relied on their ongoing, evolving relationship with the national government. Here, the focus on the policy mandate, with flexible implementation strategies, has opened new avenues for impact at scale. For example, in October 2022 the national Ministry of Health invited Ms. Tran’s team to introduce the EJOL model to health managers of 35 provinces in a Training of Trainers course. Then, on January 6, 2023, the Ministry of Health approved a national guideline for health workers on early childhood development, including examination and counselling for children from birth to age five. EJOL led the development of that guideline, which refers to EJOL as a learning source for parents that health workers nationwide can recommend.

In addition to policy alignment and implementation flexibility, EJOL cited one more key element of their approach to government embedding for scaled impact: sharing success, ownership, and credit:

With any encouraging news, we update [our government partners], the way friends chat. They are the insiders. They know about the program very well. Even though as leaders they are very, very busy—they could not attend every event—but they know exactly what happened and the impact after one month or two months of implementation under their direction, and that makes them happy. (Ms. Tran)

We ask them to join us at public events…. We wanted the program to be something they could claim with pride, and that they could say with confidence harmonized with their own aspirations and goals for the country. (Prof. Fisher)

We’ll make sure the director, in her terms in that position, would have the credit. (Ms. Tran)

Looking ahead, EJOL will build on its national relationships to undertake a phased expansion to provinces beyond Ha Nam and to urban and industrial zones. The recently developed digital delivery model may be especially valuable in such zones. Remote, underserved areas, where in-person service will continue to be a priority, are another target for expansion. In the longer term, EJOL’s goal is to have the entire nation served by some form of the program.

Throughout, EJOL’s long-term transition is based on its long-term investments in government engagement; its flexible approach to supporting government policy and acting on opportunities that then arise; and its willingness to share successes with government leaders as insiders in the program.

Foundational Considerations

The thematic framework we shared in advance with the EJOL team was based on the foundational observation that effective early childhood programs tended to emphasize high-quality human relationships and to “focus on recognizing and building human dignity, respect and agency of the people the program aims to serve, and of everyone involved in delivering, supporting or enabling the work” (Barth et al., 2023, p. 1). Such approaches hold promise for effective scaling, since respectful relationships at the front line can in turn spread throughout a delivery system in the transition to scale (Barth et al., 2023). These ideas resonated with our EJOL respondents:

Some of these terms, I believe have been really of fundamental importance to us. That is, respectful relationships are just crucial, between the partners, but very much in our relationships with people in the community. I really like this statement here [in Barth et al., 2023] that respectful relationships are contagious and that if we behave respectfully towards the community-based workers who implement this program, they are more likely to be respectful towards the families who receive their care. So, I think that’s articulated beautifully here. (Prof. Fisher)

Ms. Tran noted that EJOL stakeholders “feel ownership, and they are respected, which is rarely seen in community development projects in Vietnam.”

For EJOL, a key to maintaining respectful relationships is EJOL’s ethic of transparency, so all stakeholders are informed about programs, plans, and results. As Ms. Tran explained, “Everything is shared at the beginning, everyone knows exactly how the project will be implemented, the budget, who will be involved, what to expect.” Likewise, Prof. Fisher described transparency as a key EJOL “principle,” whereby “anybody with an interest in this program is fully informed about what’s involved, what’s required, what are the rules of engagement with us.”

Barth et al. (2023) also highlighted individual rights and gender equality, and these ideas were clearly core aspects of EJOL’s approach. As Fisher et al. (2023) report in relation to gender equality, EJOL “took a rights-based approach” and “emphasized the benefits of kindness, affection, and trust towards women, and the harms of criticism, coercive control, threats, and violence” (p. 321). In our interviews, the EJOL team repeatedly emphasized gender equality and brought this priority to life at the household level:

In all phases we would like to reduce the workload on the shoulders of women. So we encourage mothers to bring their husbands and we try to involve men as much as possible in all the material, with enrichment to encourage men to come. We award a prize to families who have both parents come for learning. (Ms. Tran)

We are very conscious that women already do a disproportionate share of unpaid work. And the last thing we wanted to do was make that worse. And, and we really believe that families flourish when the work is shared fairly. I think we achieved some remarkable, changes in men’s behavior, but not always sustained. (Prof. Fisher)

The two EJOL leaders also elaborated on their approach to respect for communities in ways that went beyond the content of Barth et al. (2023). In particular, they connected their respect for communities to the priority they place on community benefit: “For the foundation of respect, we always think of community benefit” (Ms. Tran). For example, they noted that research must not be extractive, but should rather give back to families and communities. EJOL declined involvement in a potentially exciting international research project involving brain scanners because the project’s leadership could not answer the question of how participation would benefit Vietnamese families. EJOL also turned down funding from a large pharmaceutical company because the requirement to use the company’s logo would compromise independence and trust.

Cross-cutting Lessons

Ms. Tran reflected on the overall relevance to the two EJOL leaders of the thematic framework used for this developmental evaluation:

I think it is very closely related to EJOL, because on the pathway for transition to scale right now we are going through those five themes in every element of action with the government, with community-based facilitators, with Monash University, and with partners in WHO, UNICEF, and NGOs in Vietnam.

Ms. Tran’s way of describing the framework’s relevance is also emblematic of an additional theme that cut across EJOL’s various responses: EJOL consistently saw their role in the transition to scale as working with both local families and communities and larger partner agencies, in an integrated, aligned way. They described how they identified local priorities and looked for harmonies with provincial and national policy; they could then present EJOL as meeting the aspirations of both. Their emphasis on research and data also involved putting out information to both community and provincial and national partners, and they described sharing ownership and building for the long term with the same spectrum of partners. The repeated appearance of this integrative approach in EJOL’s responses across our thematic framework suggests that maintaining a local-to-national perspective was an important driver of success in EJOL’s transition to scale.

Relatedly, another cross-cutting theme was the importance of sharing knowledge and information: transparency. We noted that the two EJOL leaders brought this up as part of their responses to all five themes covered in the interviews, and also as a foundational consideration. It represents a practical strategy that could be broadly applied in programs that work with diverse stakeholders, including in transitions to scale.

Finally, the reflective discussions in the developmental evaluation helped the two leaders derive lessons for their own future development. For example, our discussions brought out the importance of long-term funding to support monitoring, evaluation, and learning, and underscored an aspect of their work that they resolved to pursue more explicitly going forward: the importance of expressing appreciation at the front line. As Prof. Fisher put it, “I think spontaneously a lot of appreciation is expressed, but really making it intentional, an explicit activity as part of every interaction would make it become a program principle. I think that would definitely strengthen our next iteration.”

Discussion

Our study’s focus on EJOL’s transition to scale has enabled us, in the style of developmental evaluation, to compare the strategy set by EJOL’s senior leaders with themes from other transitional efforts synthesized in Barth et al. (2023). We found considerable resonance with these themes, but also noted that EJOL’s way of bringing those themes to life was often distinctive. For example, EJOL’s commitment to transparent sharing of quantitative and qualitative information with both local and provincial and national partners helped build commitment and trust with all those partners and supported the transition to scale in each of the thematic areas we reviewed.

Likewise, EJOL’s consistent efforts to ensure alignment of goals across communities and agencies, so that every participant experienced benefits, provided a bridge between local aspirations and provincial and national policy that reinforced the transition to scale. This bridge was in turn reinforced by systematic use of data both for rigorous impact evaluations and for rapid monitoring and adaptation, enabling necessary support at provincial and national levels while also energizing the front line for high-quality delivery.

EJOL’s origins in years of rigorous formative research, its continued commitment to sophisticated use of data, and its application of internationally developed content may at first glance suggest a kind of distance from individual human stories. Our results suggest, however, that their success in transition to scale involved combining their research orientation with remarkable capacity to build relationships with people from all walks of life, so that their investment in those relationships effectively complemented their strong commitment to data. The resulting combination of effective use of analytical data and understanding and support for the perspectives of everyone involved in their programming gave EJOL a route to tackling human resources and quality-of-delivery challenges that have been found to threaten scaled-up implementation (Cavallera et al., 2018; Hartmann & Linn, 2008; Hill et al., 2023; List et al., 2021). Lessons for EJOL’s future expansion arising from the developmental evaluation underscore the importance of continuing to build capacity for both relationships and data analysis: EJOL’s reflections identified a need for funding to support long-term monitoring and evaluation capacity and also brought forward the idea of being more systematic, throughout EJOL’s operations, in explicitly appreciating people’s contributions.

Comparisons with Comprehensive Scaling Frameworks

The introduction to this paper summarized a variety of comprehensive scaling frameworks developed by implementation researchers and practitioners. These frameworks reach considerably beyond the limited set of transition-to-scale themes from Barth et al. (2023) that formed the basis of our developmental evaluation. Still, aspects of the comprehensive frameworks that apply directly to the transition-to-scale phase generally resonate with EJOL’s experiences reviewed here, in alignment also with themes from Barth et al. (2023). For example, engagement, coordination, and alignment of all stakeholders, from the community level through to government policymakers, are all recommended in the scaling literature; EJOL’s work in these areas was highlighted in our treatment of Theme 1 above (cf. Cooley, 2016; Kohl & Linn, 2021; List et al., 2021; Simmons et al., 2007). Likewise, EJOL’s transition to scale featured learning and adaptation based on evidence; ongoing work with government leaders; and attention to organizational dynamics. These too are recommended in the literature; they emerge in our EJOL discussions largely under the rubric of themes 2 and 3 above. (cf. Cavallera et al., 2018; Cooley, 2016; Hartmann & Linn, 2008; Kohl & Linn, 2021; List et al., 2021; Simmons et al., 2007). Moreover, the first imperative articulated by Simmons et al. (2007), calling for a “normative rationale” grounded in “ethical principles of human dignity and human rights” and “a people-centered vision” (p. ix) was central to EJOL’s approach in this phase and is reflected in the discussion of foundational considerations in our results reported above. In each case, the developmental evaluation also brought out distinctive approaches taken by EJOL to enact these broad recommendations.

At the same time, EJOL’s work brought to life other themes we reviewed in the developmental evaluation—planning for long-term government embedding and supporting frontline empowerment, for example. These areas also harmonize with the comprehensive frameworks, but here EJOL’s approach to the transition to scale seemed especially distinctive. For example, EJOL’s work with frontline workers combined a community-based recruitment and empowerment strategy with a central management approach based on rich data, rapid feedback, and appreciative follow-up (Theme 4). The emphasis on appreciation at the front line resonates with the strength-based approaches from the general management literature (Aguinis et al., 2012). In the other direction, EJOL’s long-term strategies for embedding the principles underlying their program into government agencies can be linked to the literature on systems change (Theme 5).¹⁹

Conversely, other important aspects of scaling brought out in the comprehensive frameworks and related literature, but less of a focus for EJOL’s senior leadership during the transition to scale phase, were not addressed in this small developmental evaluation. However, they may prove highly relevant to the long-term success of EJOL and other programs. For example, we did not explore how, in advance of the transition and even of the piloting, the EJOL team may have planned and designed for scalability in both the content of intervention and the growth strategy. Along these lines, it is noteworthy that the online and hybrid models, which promise improved scalability over the in-person approach, have yet to be tested for effectiveness; there may be a tension between scalability and impact of those models that would need to be addressed. Various authors (e.g., Cooley, 2016; Hartmann & Linn, 2008; Kohl & Linn, 2021; Lyon, 2021; Simmons & Shiffman, 2007; Simmons et al., 2007) suggest that earlier attention to such scalability concerns would have been preferable.

Looking ahead to nationwide, population-level scaling of EJOL, the challenges of spillover and general equilibrium effects emphasized by List et al. (2021) will likely need attention. As List et al. observe, both spillovers (e.g., ripple effects of improved practices that extend beyond the treatment group to the controls) and general equilibrium (e.g., difficulties in recruitment arising from changed market conditions) can pose evaluation and implementation challenges at large scales. Moreover, new resources will be needed to sustain rigorous evaluation and learning as the work approaches population scales across Vietnam (cf. Grantham-McGregor & Walker, 2023; List et al., 2021; Kohl & Linn, 2021; Simmons et al., 2007). To this end, enhancing local research capacity and building local research partnerships will be important avenues for advancing learning across the full range of scaling challenges. Meanwhile, the two EJOL leaders reported that the scaled implementation in Ha Nam through the government system that implements immunization has already led to data reporting challenges, since the existing reporting system is not geared to early childhood data. EJOL hopes to address this challenge at the policy level.

Comparisons with Experiences Elsewhere: The Reach Up Program

Araujo, Rubio-Codina et al. (2021b) describe a scaling up sequence of three experimental implementations of the Reach Up program. Reach Up (Walker et al., 2018) is an evidence-based early childhood parenting curriculum generally delivered through home visits, but sometimes in group sessions, akin to EJOL’s approach. Araujo, Rubio-Codina et al. consider (1) a small pilot in Kingston, Jamaica, with 64 children (Grantham-McGregor et al., 1991); (2) a subsequent adaptation, which in the terminology used here would be part of a “transition to scale,” carried out with 720 children in Colombia (Attanasio et al., 2014); and (3) the population-scale “Cuna Más” implementation by the national government of Peru, evaluated when it was serving over 67,000 children (Araujo, Dormal et al., 2021a).

Araujo, Rubio-Codina et al. (2021b) highlight the decline in reported effect size in the transition to scale, from 0.88 standard deviations in Jamaica (generally regarded in the early childhood field as very large) to 0.18 in Colombia, to 0.10 (generally regarded as small, but not negligible) in Peru. They note, for example, that in Jamaica supervision and mentoring of frontline workers was more intensive, featured more favorable mentor–mentee ratios, and was carried out by better qualified personnel (in fact, the researchers themselves) than was possible in Colombia. EJOL’s approach to frontline management described here—including data-rich emphasis on recognizing and building on strengths—may have helped the program maintain effect sizes greater than 0.4 in a transition-to-scale trial with 1,245 children across the treatment and control groups (Baek et al., 2023; Fisher et al., 2023). These frontline strategies are promising avenues for addressing human resource challenges highlighted, for example, by Cavallera et al. (2018) and Hill et al. (2023).

As EJOL’s leadership considers possibilities for transition to nationwide, population-level implementation, Araujo and co-authors’ account of the Cuna Más experience in Peru highlights challenges that may apply in Vietnam as well. Contrasting Colombia’s case with Peru’s, Araujo, Rubio-Codina et al. (2021b) note that low effect sizes in Peru (0.10 standard deviations on the intent-to-treat estimate) seemed to arise not so much from problems with quality of delivery, but rather from coverage and frequency challenges. Despite dedicated efforts by Peru’s Ministry of Social Inclusion and Development, program enrollment was limited, and enrolled families received only about half the number of intended visits. Assuring full delivery at large scale will be an important challenge for EJOL’s expansion; in particular, coverage and frequency problems, in the forms encountered in Peru, may arise in models that involve online delivery, a key part of EJOL’s scaling plans (cf. Lyon, 2021, p. 259).

Wider experience with Reach Up implementation also offers hopeful lessons for analogous early childhood parenting programs like EJOL. EJOL is delivered through group sessions, for example, and researchers in Bangladesh (Hamadani et al., 2019; Hossain et al., 2023) report considerable success in transition to scale of a Reach Up adaptation using group sessions rather than individual home visits (Hamadani et al., 2019; Hossain et al., 2023). More generally, Jervis et al. (2023) analyze 16 implementations of Reach Up, at multiple scales, offering lessons and challenges for scaled-up implementation. For example, effect sizes were larger in interventions that targeted undernourished or low-birthweight children and in interventions delivered by specially recruited workers rather than existing government systems. Reviewing these results and wider experience with scale-up efforts for similar programs, Grantham-McGregor and Walker (2023) highlight delivery system challenges (noting, for example, existing burdens on health systems); the importance of ensuring equity across populations served; the need for feasible, scalable assessment instruments; and the importance of building capacity and expertise in low- and middle-income countries. Each of these represents an important focal area for development as EJOL evolves towards national scale.

Limitations

This paper has important limitations inherent in its status as a report on a single project, with a narrow focus on that project’s strategy in its transition to scale, as that strategy related to the framework articulated in Barth et al. (2023). As noted above, important considerations for scaling that go beyond this focus were not considered here. Moreover, our information derives only from written sources and interviews with the two principal leaders of the EJOL program itself. We did not conduct field visits or interview EJOL’s staff (beyond the two leaders selected as key informants) or partners; rather, in accordance with standard developmental evaluation approaches (Patton, 2011), we worked jointly with the two EJOL leaders to identify lessons. In this spirit, for example, we shared emerging themes with the two in advance of our interviews with them. Thus, while our results credibly reflect the perspectives and strategies those leaders shared with us, they do not constitute an independent review and cannot provide a basis for assessing the program as a whole or for rigorous attribution of causality to the strategies the respondents described. Moreover, although the correspondence between themes derived from work elsewhere and the strategy of the EJOL leaders is suggestive, the details of dependence on program content, context, and population were not studied here. For all these reasons, any generalization of our findings will require further research. Finally, as scaling is still in progress in Vietnam, our reports constitute a snapshot of the current stage of the work, in the transition to scale, and not a completed picture.

Conclusion and Recommendations

This developmental evaluation sought to explore, through reflective interviews with the senior leaders of a program—EJOL— experiencing promising results in transition to scale, how the scaling strategies those leaders used compared with a thematic framework compiled from a wide range of transition to scale experiences. We found considerable resonance, and the comparison seemed helpful to the EJOL team as they reflected on current and future scaling strategies. These results suggest that these themes, and EJOL’s ways of applying them, merit consideration by practitioners and researchers working on transitions to scale in early childhood programs. Contexts differ, and we do not anticipate one-size-fits-all answers. Rather, we recommend that programs consider which aspects of the transition to scale strategies discussed here may apply to them, and how EJOL’s approaches may need to be varied or adapted to their own contexts. Those approaches may be summarized as follows:

EJOL consistently invested in vibrant, respectful relationships with stakeholders at the local, provincial, and national levels. In every case, EJOL emphasized both careful listening to understand the circumstances and priorities relevant to each stakeholder, and transparent information sharing as a way of building trust and maintaining alliances. Listening first to local communities, they worked to organize their program in a way that would engage existing, committed local service providers and align with local, provincial, and national priorities. They shared program ownership and credit in a way that bridged these different domains. The strength of the human relationships built this way sustained the transition to scale by keeping all relevant stakeholders effectively engaged and working in a consistent direction.

In a similar spirit—i.e., respectfully linking local and global domains by understanding the priorities of both and consistently sharing information with them—EJOL built sophisticated data and analytical capacities both to undertake rigorous impact research and to regularly harvest and use monitoring data and feedback from the field. They used a fully digitized system to collect quantitative and qualitative data which they analyzed monthly, identifying ways to improve the performance of specific local delivery units and of the program as a whole. This persistent attention to local delivery, with a view to continuous improvement, seems to be one of the ways EJOL addressed the human resource and quality of delivery challenges in scaling (cf. Cavallera et al., 2018; Hartmann & Linn, 2008; Hill et al. 2023; List et al. 2021). Meanwhile, by collecting and analyzing impact data to an internationally publishable standard, they were able to satisfy important government preconditions for scaling up the program.

In working to enable government agencies to take shared ownership of the program, EJOL recognized that agencies are composed of people, and that having passionate champions within agencies would be essential for effective, scaled-up implementation. EJOL therefore identified a champion in each of their partner agencies and cultivated active, trusting, personal relationships with those champions.

EJOL complements its data-rich response to frontline delivery challenges with an approach to training and supporting frontline workers that emphasizes support, encouragement, and appreciation. Hallmarks of this approach include public recognition of good performance, friendly responses to emerging problems, and transfer of decision-making to frontline providers as their experience grows. EJOL has also focused their continuous improvement strategy on modifying the program to better fit the stressed schedules of workers and families. This was a way to address the challenge of time shortages reported in, for example, Hill et al. (2023).

Finally, EJOL took a long-term approach to its engagement with government partners and worked to share success, ownership, and credit with them. That they also took an equivalent shared ownership approach to their work with local communities and frontline workers is emblematic of their consistent effort to productively combine local, provincial, and national engagement. It is also a reminder of what they saw as foundational: an ethic of respect for every person and a commitment to nurturing trust.

Concluding Recommendations

EJOL developed its transition to scale strategy within a specific context in Vietnam. The approach we recommend based on our findings about EJOL’s experience is that practitioners and researchers working on transitions to scale elsewhere review the strategies summarized above in light of their own programmatic contexts, with a view to identifying promising avenues for adaptation. If they decide to adapt some or all of EJOL’s strategies, we hope they do so in an empirical spirit, trying out promising approaches and tracking results. In particular, we hope those results will in turn be widely reported, so the field can learn more about what strategies are effective in what contexts (cf. Informing Design, 2019; Simmons et al., 2007; Yousafzai et al., 2018). Researchers have a vital role to play here, especially in developing and using rigorous measures of hypothesized active elements of transition to scale strategies, elements such as (in EJOL’s case) transparency, relationship quality, stakeholder alignment, and use of qualitative and quantitative feedback for learning and adaptation. This in turn will enable the field to build from encouraging, preliminary findings like those reported here to fuller understanding of practical approaches to scaling up whole child development everywhere.