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Limitations in programme scale, infrastructure and resources also raise important questions regarding the sustainability of these affirmative action programmes.
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First, for the objective of this review it was essential that studies explicitly reported the role of external funding in programme scale-up so that any observed impacts could be linked to changes in external funding.
When looked at in absolute terms, programme scale up has been far more dramatic in Gauteng than in the other two provinces.
In 2005, following the PMTCT programme scale up to the rest of the sub-cities, the counselling and testing utilization dropped to 32.1%95%5% CI 31.5-32.7).
All studies found that the increased availability of external funds resulted in a degree of programme scale-up or in the introduction of new activities.
The best guess estimate developed by international researchers for the baseline rate of circumcision in Rwanda prior to programme scale-up is demonstrated with the dashed line near 1000 circumcisions per month (Bollinger and Stover 2009a).
For example, programme scale-up in impact assessments by Otten et al. (2009) and Reniers et al. (2009) was likely enabled by external funds, but this was not made explicit and so we excluded these studies.
As Bryce et al. (2011) have noted, randomization is rarely possible in programme evaluations and, with continued scale-up of maternal and child survival programmes, finding 'virgin' comparison areas is increasingly challenging.
In a programme of this scale, small variations in programme protocol are inevitable between sites.
While studies have shown the effectiveness of some CHW programmes, implementing these programmes at scale and in resource-constrained settings has proved difficult [ 3].
Taking a programme to scale in Mongolia will not look the same as in Bangladesh.
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