Table 3. Key Features of Aid Effectiveness Principles Enabling (+) and Undermining (-) Scale-up of Innovations .

Aid effectiveness Principle	Ethiopia	Northeast Nigeria	Uttar Pradesh, India
Country ownership	(+) National government coordination of donor-funded programmes fostered government ownership, increasing the possibility of innovations being scaled-up	(-) Limited state funding, meant rural primary healthcare was largely donor funded and driven, inhibiting state government ownership and scale-up of innovations	(+) State government champions fostered introduction of externally funded innovations, increasing the likelihood of them being scaled
	(-) Attrition among government officials made ownership of an innovation transitory
Alignment	(+) Externally funded programmes expected to align with national health strategies and increasingly, implementers supported government work packages, enhancing prospects of innovations being taken to scale	(-) Externally funded programmes expected to align with government strategies, but limited government coordination of donor activity meant potentially scalable innovations were missed	(+) Economic development in India reduced reliance on external aid; externally funded innovations have had to align with national and state-level government strategies to be considered for scale-up
Harmonisation	(+) National government-led Technical Working Group on MNH strengthened coordination, reducing duplication of donor-funded innovations and fostering better information sharing	(+) Federal government-led Maternal and Newborn Health Core Technical Committee encouraged collaboration among some donors to avoid duplication of effort	(+) The Health Partners’ Forum enabled partner programmes to be mapped to avoid duplication and identify scalable innovations
	(-) NGO implementers’ involvement in the Technical Working Group limited to responding to technical queries	(-) Weak capacity of the government’s Maternal and Newborn Health Core Technical Committee to coordinate donor-funded innovations and programmes	(-) Health Partners’ Forum had limited engagement from donors and leadership from government
	(-) Multiple donors and implementers working on parallel health innovations and programmes meant competing interests, priorities and donor-led ways of working, leading to parallel procedures and increased health worker workloads, thus reducing their time for implementation
	(-) Collaboration among implementers was challenging because of their need to claim attribution for innovation outputs as evidence to report to their funders
Transparency and accountability	(+) Technical Working Group promoted better transparency and information sharing, which improved understanding of scalability of innovations	(-) Transparency hampered by limited government capacity for donor and implementer coordination at federal and state levels	(+) Health Partners’ Forum was seen as helping to encourage transparency and developing as a space to share information about innovations
			(-) Health Partners’ Forum was still largely nascent
	(-) Parallel donor and implementer monitoring and evaluation and information systems limited opportunities to compare results about innovations and increase understanding
Aid predictability	(+) The pooled Millennium Development Goals Performance Fund offered some flexibility for Ministry of Health to fund new innovations at scale	(-) Security situation meant donors were becoming reluctant to fund pilot innovations for potential scale-up	(+) Relatively high levels of government funding mitigated the negative impact of fluctuations in external funding
	(-) Some donors continue to emphasise project-based funding, which is vulnerable to shifting global health priorities
	(-) Short time frames for donor-funded innovations limited the time available to convince government of their value for scale-up
Civil society engagement and participation	(+) By working collectively, civil society organisations were beginning to influence government decisions and priorities for health	(+) Civil society was starting to influence government decisions and priorities for health	(+) Through the Health Partners Forum, government was becoming more responsive to civil society organisations advocating on health needs
		(-) Limited awareness of rights undermined civil society organisations’ ability to hold government to account

Key: (+) = enabler, (-) = barrier.