Table 1 Overview of country-specific scale-up structures and approaches (scale-up strategies)

Steering Group (user organization)

The steering group consists of national-level stakeholders from the Ghana Health Service, the MoH and the Christian Health Association of Ghana. It also includes the Regional Director of the region where the intervention is being implemented

The steering group consists of four directors of relevant MoH departments (Quality Management, Human Resources Management and Development, Planning and Policy Development and Clinical Medicine), one director from the Ministry of Local Government and one from the Department of Human Resource Management and Development in the Office of the President and the Cabinet

Steering group members were mostly commissioners of relevant departments of the MoH (Human Resource Management, Health Services (Planning) and Quality Assurance and Improvement) and included the Director-General. However, the steering group did not take off as a group. Therefore, two adaptations were made: 1) a steering group focal person was appointed, who could regularly update the other members; and 2) present to technical working groups at the MoH, to which some of the steering group members belonged

Resource team

Six members (varied over time). The resource team comprises DHMT members who have been involved in the intervention, and two regional actors (including the Regional Director), of which one is the chair. When district numbers increased, the number of resource team members also increased

Eight members. Three members are deputy directors from relevant departments of the MoH and the Ministry of Local Government. Three members are MoH officers at zonal/satellite level, and one is a District Director of Health and Social Services. One team member is from the staff development institute

Four members, drawn from the departments to which the previous steering group members belong (mentioned above). They are mainly assistant commissioners and principal officers

Horizontal scale-up approach

The horizontal scale-up took place in districts of one specific region. The districts were selected based on the social development and service delivery performance ranking and geographical location. Selection of districts was discussed by the country team and the resource team and confirmed by the steering group

The districts were selected based on a minimal number of development partners working in health system strengthening, so that the impact of the intervention could be better measured. The district groups were selected by the country team, resource team and steering group

The intervention took place in nine districts, equally distributed across three regions. The district selection was guided by the need to facilitate peer-to-peer/cross-district learning within a region. Hence, one of the districts in each district group had been involved in the pilot phase of the intervention, and two other, new districts share borders with that district. The district groups were selected by the country team, resource team and steering group

Vertical scale-up approach

No clear entry point for integration or institutionalization of the intervention has been identified (yet)

The vertical scale-up of the intervention is envisaged by integrating the intervention in the activities of the zonal/satellite offices (responsible for technical advice to DHMTs), which are part of the Quality Management Department of the MoH. The intervention workshops are envisaged to be integrated into their quarterly review meetings, and satellite officers will take over the facilitating roles of the country team and resource team. Furthermore, elements of the intervention have been integrated into the national integrated supportive supervision tool

The vision is that certain components of the intervention will be integrated into the revised version of the MoH’s quality improvement strategy for 2021–2025