Article Text

Original research
Role of twinnings in scaling up innovative solutions across Europe
  1. Cláudia Campos1,
  2. Robbin Kappelhof2,
  3. Joana Carrilho1,
  4. Luis Midão1,
  5. Diogo Henriques1,
  6. Elísio Costa3
  1. 1Competences Center on Active and Healthy Ageing, Center for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal
  2. 2European Regional and Local Health Authorities, Bruxells, Belgium
  3. 3Department of Biological Sciences of the Faculty of Pharmacy, Competences Center on Active and Healthy Ageing, Center for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal
  1. Correspondence to Dr Cláudia Campos, Universidade do Porto Centro de Competências em Envelhecimento Ativo e Saudável, Porto, 4050-313, Portugal; cscampos{at}


Introduction Twinnings are cross-border knowledge exchange activities where two or more organisations learn from each other’s experiences and are often used as a scaling up mechanism.

Objectives This paper discusses the importance of twinning activities in scaling up by promoting community building, knowledge sharing and innovation transfer among stakeholders in European countries. It explores the role of twinnings in the scaling up model of the European Innovation Partnership on Active and Healthy Ageing) and the Innovation Networks for Scaling Active and Healthy Ageing (IN-4-AHA) project.

Methods The study employed a qualitative approach, drawing insights from various sources, including the Scale AHA study (2017), the IN-4-AHA’s scaling up model and twinning reports.

Results The findings reveal that twinning activities provide stakeholders with a unique opportunity to learn from the know-how of other like-minded partners, improve the quality of their work and iterate on their innovations. They also highlight that twinnings are particularly relevant for some stages in the scaling up process, such as in the assessment of a network of potential partners and during the evaluation of the environment, the innovation could potentially be transferred to.

Conclusion Twinnings are highly regarded as community-building and knowledge-sharing activities with clear advantages for companies and other stakeholder groups. Including twinning activities in the scaling up model has proven benefits for companies and projects that have a strong need for community building and innovation transfer.

  • Health Care Economics and Organizations
  • Health Services Administration
  • Health

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study.

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  • The existing scientific knowledge on the subject suggests that scaling up is crucial for organisations to achieve growth and maintain competitiveness. Studies have shown that rapidly expanding firms contribute significantly to employment and economic advancement, and that entrepreneurship and innovation can be major driving avenues growth, but require supportive government initiatives. The European Union has implemented various policies and initiatives to promote scaling up, including twinnings, which involve knowledge exchange and technology transfer. Our study explored the role of twinnings in fostering digital innovation for active and healthy ageing in Europe, revealing their importance in building cross-border collaborations, sharing innovative practices and supporting community-building efforts.


  • This study adds insights into the specific role of twinnings in promoting digital health innovation in Europe. It offers an understanding of the advantages, difficulties and results of twinning activities, contributing to our comprehension of how they influence knowledge exchange and the sharing of innovation among diverse European regions.


  • Our study highlights the value of twinnings as a tool for promoting cross-border innovation exchange in the field of active and healthy ageing. Additionally, it may encourage practitioners and researchers to consider twinning activities as a means of enhancing knowledge transfer and collaboration in the digital health sector.


Scaling up encompasses the act of augmenting an organisation’s magnitude or broadening its undertakings to accomplish progression and enhance its market presence. Hence, it emerges as a pivotal tactic for enterprises aspiring to sustain competitiveness and attain enduring success. Research conducted by the Kauffman Foundation1 and McKinsey & Company2 reveals that rapidly expanding firms are the foremost generators of employment, make substantial contributions to economic advancement and yield superior returns for stakeholders. Furthermore, a study by the Brookings Institution highlights the role of entrepreneurship and innovation in driving growth and emphasises the need for supportive policies and infrastructure to enable successful scaling up.3 Aiming to influence the process at structural levels, the European Union (EU) has implemented various policies and funded initiatives to promote scaling up, mainly the European Structural and Investment Funds that have funded initiatives such as Digital Innovation Hubs, and the European Innovation Partnership on Active and Healthy Ageing (EIP-AHA) that promoted innovation in the field of healthy and active ageing to improve the quality of life of older people.4 5 Among the many instruments employed by these initiatives, twinnings were notable activities. In a broad definition, twinning is a partnership between organisations of different sizes in which the larger organisation provides mentorship, resources and expertise to help the smaller organisation grow and scale up.6 By adopting this approach, the smaller organisation can acquire knowledge from the larger organisation, while the larger organisation can also benefit from fresh perspectives and innovative ideas from the smaller organisation.7 At the level of the European Commission, twinnings are an instrument to facilitate the cross-border transfer of knowledge and technology. They have been used for institutional cooperation between Public Administrations of EU Member States and of beneficiary or partner countries.8 Twinnings are cross-border cooperation programmes, that allow knowledge exchange and technology transfer between different EU regions: one being the originator (the developer of the initiative/innovative solution) and the other being the adopter. Participants establish an action plan to learn and/or implement the innovation/good practice. Other authors have already established the value of twinnings as an integral part of scaling up innovations.9

The Innovation Networks for Scaling Active and Healthy Ageing (IN-4-AHA) project (2020–2022, funded by the European Union’s Horizon 2020 research and innovation programme) aimed to promote digital innovation in the field of active and healthy ageing. The project sought to coordinate and support the scaling up of mechanisms developed by EIP on AHA, as well as bring together new actors in the field and provide opportunities for testing and sharing innovations. Hence, this article presents a summary of the results of the IN-4-AHA twinnings programme10 and explores the value of twinnings as a tool for supporting the transfer of innovation and sharing of knowledge across different EU regions.

Materials and methods

The rationale for data collection and analysis was threefold: recruitment process, programme implementation and results evaluation. An open call for twinnings was launched in November 2021 and January 2022 (, accessible to IN-4-AHA’s community members.11 A maximum of 10 originator-adopter pairs could be selected, and awarded €5000 each for their travelling and accommodation expenses, to be used between 1 January 2022 and 30 October 2022. The only exclusion criterion was if the participants’ organisation was not part of a Reference Site,12 while in opposition, having a digital, transferable, socially and healthwise impactful and cost-effective innovation was valued. The evaluation and selection of applications were executed by the IN-4-AHA consortium members and external representatives from the Reference Sites Collaborative Network.13 The chosen twinning projects signed a cooperation agreement contract between themselves and the University of Porto—the IN-4-AHA partner responsible for the programme—and were tasked with three deliverables: (1) a work plan (application form), (2) a mid-term report and a (3) final report. These templates can be seen in online supplemental appendices 1–3, respectively. These reports were comprised of multiple choice and open-ended questions, meant to collect both quantitative and qualitative information, which constitutes the backbone of the data analysed in this report.

When it came to data analysis participants were given the freedom to share as much information as they desired without any limitations on character count. However, this presented some challenges in identifying key trends within the mostly qualitative information provided. To overcome this, the answers from open-ended questions were grouped into logical themes using stochastic decision lists and keywords were coded and interpreted.14–16 The results were presented in a frequency distribution, with the ‘n’ representing the number of times a specific category or keyword was mentioned in the raw data. However, due to the low statistical significance of the total number of answers, the results were primarily presented in graphic form to provide a general overview of the characteristics of the twinning programme and protect any potential intellectual property or personal information shared in the reports.


The twinning programme involved stakeholders from eight European countries, with southern European countries being particularly well-represented. Spain had the most participation with six, followed by Portugal with five. Spain’s Galicia, Andalusia and Catalonia regions were present in the twinnings, while Portugal was represented by Coimbra, Algarve, Lisbon and Porto. The UK also had three participants, with two from Northern Ireland and one from Scotland. Among the stakeholders, research and academia had the most participation, followed by innovators and policymakers. This data suggests that university personnel and researchers from southern European countries are particularly active in the programme and may have more flexibility to participate in expert exchange activities. It also highlights that for stakeholders from organisations such as innovators, different arrangements may need to be made to accommodate their needs, such as reimbursement for daily rates.

The twinning pairs did not engage in any adoption or acquisition activities. Instead, the majority classified their activity as ‘Knowledge exchange and training’ and/or ‘Adaptation’. Out of 10 twinning pairs, 3 identified as both types. Specifically, 60% (n=6) of participants classified their twinning as ‘Knowledge exchange and training’ and 40% (n=4) as ‘Adaptation’. The innovations shared were primarily ‘apps/web platforms’ (n=7), followed by ‘training programs for patients/users’. Many twinning pairs chose more than one option to describe their innovative practice, and the twinning programme had a strong focus on digital health solutions. Overall, most of the innovations were considered mature, with a TRL (Technology Readiness Level) of 7 or higher. Specifically, 60% (n=6) of the twinning innovations were reported to be at a TRL of 9. The main characteristics of the twinning projects can be found in table 1.

Table 1

Innovation Networks for Scaling Active and Healthy Ageing twinning innovations

In terms of implementation of the programme itself, half of the twinning pairs (n=5, 50%) reported having based their activities solely on in-person meetings and informal knowledge exchange and most twinning pairs have claimed to not have sought any sort of funding (n=4, 40%) other than the IN-4-AHA funds, or to be thinking of applying for other European Comission (EC) funded projects (n=4, 40%), three adopters referred using funds from their national or regional budgets (n=3, 30%) and one (n=1, 10%) to have used money from their own organisation. At the end of activities, the overall budget execution was 50%, which roughly translated to €25 000.

For originators, on the question of ‘processes and time for adoption (post-development)’, originators have answered it in three different ways by: (1) providing general information on how long their innovation took to develop, and hence, how long it could take for the adopter to do the same (n=3), (2) how long it took for the innovation to be launched, in general (n=2) and (3) how they envisioned that the innovative practice could continue to be implemented by the adopters in the foreseeable future (n=3). On the issue of costs and outcomes, some originators chose to focus on costs (n=5) while others on the outcomes of the implementation of the innovative practice (n=2). Three projects have provided no data. As for the ‘business case for sustainability and scaling up’, most adopters have stated that no study has been prepared as of the time of the finishing of activities (n=7). Then, three adopters referred that while no formal business case had been made, there were exploitation avenues being considered for the continuation of the project—and foreseeably, only then, such plans could be made. For those originators that claimed to have developed a business plan (n=3), one was based on the EU, and another by continuing the improvement of the product with stakeholders from the adopter’s region and, integration of the innovation in international social prescription platforms and engaging with future users such as care homes and health students. As for the main benefits of participating in the activity, originators referred knowledge sharing (n=7), recognition of the work developed (n=2), joint projects with adopters (n=2), exploring how the innovation could be implemented in a new setting (n=2), exploring barriers and enablers in the adopter’s ecosystem (n=1) and continuing the development of the innovation in the adopters’ ecosystem (n=1).

For adopters, when it came to the rationale for choosing the specific innovative practice shared in the twinning, three twinning pairs have indicated that ‘learning from an innovation to complement services already being provided’ (n=3), ‘gaining knowledge about international AHA ecosystems’ (n=3) and ‘learning from an innovation to develop new services and projects’ (n=3) were the main reasons. As for the needs being addressed, some twinning partners directly referred to a national health policy document that detailed priorities and strategies in healthcare investments, for others who may not be as aware of these overarching policy instruments, their regional needs assessment was mostly based on their own empirical observation and the work being developed by their organisations, such as services for cognitive decline (n=3), digitalisation of health and social services (n=3), optimisation of resources (n=3), home care services (n=2) and promotion of active and healthy ageing (n=2).

When it came to twinning participation benefits, both industry and governmental agency adopters found the twinnings beneficial as they provided opportunities to develop or improve on the services they already provided (n=5). On the other hand, new partnership opportunities (n=3) had a positive impact shared between industry, research and academia, and civil society stakeholder types and co-creation moments (n=2) with users were stated as positive outcomes by both industry and civil society.

For both originators and adopters, when it came to the development of a concrete action plan to transfer the solution from the originator to the adopter’s ecosystem, most twinning projects had not developed one (n=6). Since a significant percentage of projects in this programme were ‘knowledge exchange’ based, this was to be expected. On the question of ‘how has the twinning contributed to the adoption of the practice’, participants’ answers varied mostly according to the level of implementation of the innovations. Hence, some twinnings referred that the programme contributed by allowing knowledge transfer between parties (n=3). This included learnings that would continue to be used in the development of upcoming similar innovations (n=1), but also knowledge on the possible barriers and priorities to account for when planning the scaling up of the innovation (n=1). Others have claimed that the twinning had been a valuable tool to set the groundwork for the innovation’s adoption (n=2), to set-up contacts and provide inspiration to stakeholders (n=1) and to improve and increase awareness about the innovation (n=1). As for a fully realised completion of project activities resulting in the adaptation of innovative practice, SoCaTel was the major example. SoCaTel is already implemented in several countries, and the transfer to the Czech Republic will be a solid example of scaling up that was facilitated by the IN-4-AHA’s twinnings programme.


Testing innovative practices in various European countries provides stakeholders with a valuable opportunity to learn from like-minded partners, enhance their work quality and services and iterate on their innovations. This aspect holds a crucial place in any scaling up model, involving test phases and seeking complementary partners. Projects at all TRL levels can benefit from these activities, be it for learning, testing, adopting or selling innovation, which can be tailored to different twinning types. The EIP on AHA scaling up model17 takes this aspect into account, with two key parts: deciding what to scale up and how to scale up. The practical side of the model focused on making practices accessible to the public, starts by fostering partnerships and implementing them. In this regard, twinnings play an essential role in the scaling up process. Generally, they facilitate partnerships between stakeholders hailing from diverse regions, but in a more practical sense, they also create an avenue for these stakeholders to experiment and evaluate their innovative practices. Both the Scale AHA study18 and the IN-4-AHA twinnings activity report10 underscored this aspect by showcasing the fact that many of the difficulties felt while trying to implement the innovations during the twinnings, were context-related, and can be at least partially mitigated if there is extensive knowledge and previous interactions with the ecosystem stakeholders wish to scale up to. During the IN-4-AHA’s coordination and support action, twinnings fulfilled a similar function, creating a platform for the exchange of innovative practices across borders. Parallelly, the IN-4-AHA continued pursuing one of its major objectives: the development of a new scaling up model. The IN-4-AHA scaling up model19 targets companies and service providers. It has five different stages and two horizontal pillars. These pillars are (1) strategy, and (2) stakeholders, highlighting the importance of proper planning and keeping the individual front and centre when designing a scaling up plan. As for the five steps, they are: Learn, Plan, Pilot, Prepare and Ramp-Up. These sequential (but fluid) steps are divided into different categories, to which the innovator must pay attention before deciding if to move on to the next step.

Activities like twinnings hold specific importance for certain stages within the scaling up model. Assessing the network of potential partners during the ‘Learn’ phase serves as a clear example. Smaller companies often do not have enough scale to compete with larger enterprises, meaning that they can find great value in synergies with complementary partners. Even for large companies, knowledge exchange can be beneficial, notwithstanding the issue of corporate secrets, which often forces them to work in silos. Relying on specialist communities, such as the EIP-AHA/IN-4-AHA community, allows startups and SMEs to informally get to know like-minded partners and allows them to find common ground to collaborate on future projects. Twinning participants were facilitated in precisely achieving that. Most twinning partnerships focused on knowledge exchange and innovation adaptation, without the direct scaling up of a specific practice. Nonetheless, participants successfully established international connections and formulated plans for future collaborations. In addition, during the evaluation of the environment for the pilot suggested in the ‘Plan’ stage, stakeholders can benefit from having previous contextual information. Participating in twinnings can be a first step into a new environment and allow stakeholders to gather empirical data to prepare a pilot/test their solution in a new setting. In summary, this report has shown that twinnings are highly regarded as community-building and knowledge-sharing activities. Engaging in these types of activities offers distinct advantages for companies and other stakeholder groups. Therefore, incorporating twinning activities has demonstrated tangible benefits for companies and projects seeking robust community building and innovation transfer.

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.


The authors would like to express gratitude to the IN-4-AHA consortium and the twinning participants who contributed to this article.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Contributors CC: Guarantor, Conceptualisation, Methodology, Investigation, Data Curation, Writing—Original Draft, Visualisation. JC: Writing—Review and Editing, Supervision. RK: Writing—Review and Editing. DH: Writing—Review and Editing. LM: Validation, Writing—Review and Editing. EC: Conceptualisation, Validation, Supervision, Writing—Review and Editing.

  • Funding This article has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 101017603.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.