Doing Big Things, Fast: How Scaling With Urgency Drives Breakthroughs

In March 2020, the world locked down overnight. No pilots. No randomised controlled trials. Just bold action in the face of uncertainty. Because the stakes were clear.

But when close to one thousand women die in labour every day, or 14 million children go without basic vaccines, we sometimes take a different approach. We pilot. We phase. We treat caution as a virtue, even when the intervention is proven and the risks are low.

This poses a question: why is bold action acceptable in some contexts, but not in others?

In global health, starting small sometimes seems like the default. Especially in lower-income settings, piloting is often seen as the responsible first step. But in many cases, delay does more harm than good.

We’ve learned that when the problem is the system, rather than the solution, scale and speed are what unlocks progress. And that doing big things fast is often the only way to deliver real results in time for those who need them.

Lesson 1: Pilot When You Must. Not by Default.

Piloting has its place but, in global development, it’s sometimes treated as a default, instead of a deliberate choice. 

Sir Michael Barber, who led the UK Prime Minister’s Delivery Unit under Tony Blair, once told me there are four good reasons to pilot:

1. You genuinely don’t know if something will work.

2. You need to convince key stakeholders first.

3. You need time to build capacity.

4. You need to be seen to act for political reasons.

If none of these apply, go big fast. When the core idea is sound, it’s often better to scale early, monitor closely, and adapt as you learn lessons along the way.

Lesson 2: When the System is the Problem, Think Bigger

In global health, we don’t always lack evidence on what works. We know vaccines prevent disease. We know that skilled professionals attending births saves lives. We know that getting medicines to clinics matters.

The hard part is getting these things to happen reliably, at scale.

That’s why our focus is not on proving known interventions, but on building the systems that make them stick. When we supported the expansion of 24/7 delivery services in Punjab, Pakistan, for instance, the service model was already established. The challenge was logistics, staffing, supervision, and political support to make it work effectively at scale.

So if the intervention is proven, we sometimes flip the order: scale first, learn while delivering, and build systems that support improvement in real time.

Lesson 3: Caution Can Cost More Than Courage

Many scale-ups stall because people fear things might go wrong. But the truth is, things are already going wrong. Every day that vaccines don’t reach children, or health workers don’t show up, lives are lost.

In Ethiopia, Nigeria and Pakistan, a new postpartum haemorrhage drape trial helped birth attendants measure blood loss more accurately. It reduced severe bleeding and maternal deaths by 60%. The drape was so effective that the trial was stopped early. With its effectiveness proven, the challenge became rolling it out, fast. 

Lesson 4: Go Big, But With Guardrails

The key to going fast isn’t acting without a plan. It’s designing the right kind of safeguards.

In the world of medicine, this would look a lot like Phase 4 trials. After a drug is approved, it’s rolled out at scale, but carefully monitored for unexpected risks in real-world conditions. The same logic applies to delivery.

We call it scaling with guardrails.

This means building systems that flag problems early and enable leaders to act. When implementing the recent switch to five-dose vials to increase measles vaccinations in Pakistan, this meant tracking wastage rates, vaccinator behavior, and vaccination sessions.

So skip the pilot when you can. But only if your monitoring is strong enough to catch any problems (even extensively piloted interventions encounter problems when they scale), and fix them fast.

In Summary: What We’ve Learned

It’s easy to confuse caution with safety. But when the risks of taking action are low and the cost of inaction is high, doing big things fast is often the right choice.

Scaling innovation fast means:

• Piloting with purpose. Be clear why you’re piloting. Many times, it’s better to do big things fast.

• Thinking bigger when the system is the problem. Small-scale pilots don’t show you how to deliver at scale.

• Knowing when courage is needed, not caution. Moving slowly doesn’t always reduce danger. Sometimes, it puts more lives at risk.

• Scaling with care. Real-time monitoring and rapid response systems make fast rollout safer.

In high-stakes environments, speed and scale isn’t a threat to success. It’s sometimes what makes it possible.

For more on driving change without spending big, read our article on embracing learning to deliver the best results for citizens.