Jakob Svensson

Title: Scaling Care, Saving Lives: Evidence from an Iterative Trial in Uganda

Abstract: Many interventions that demonstrate large impacts in pilot settings lose effectiveness when implemented at scale. We study this challenge using an iterative trial embedded in the national expansion of a community health worker program in Uganda. The evaluation incorporated structured feedback into scale-up, generating interim evidence on performance that was shared with implementers to guide adaptation. Results 14 months into the scale-up showed limited gains. Consistent with a simple framework of scaling under uncertainty, we find that attenuation at scale need not be permanent: whether impact is restored depends on how organizations respond to performance signals and the trade-offs they face during.