YOU ARE HERE:
Scaling-up Asociacion de Salud Integral (ASI)
   Last updated: 16.08.02
Implementers
The Asociacion de Salud Integral (ASI) is a local non-governmental organisation (NGO) established in Guatemala City, Guatemala in 1987. Originally known as Asociacion Guatemalteca para la Prevencion y Control de SIDA (AGPCS), the organisation was founded by a group of physicians and other health care personnel who were concerned about the lack of information on HIV/AIDS available to health care workers.

ASI seeks to reduce the impact of HIV/AIDS in Guatemala through education, research and treatment.

The organisation has grown from a staff of six, running one programme in a single public hospital, to a staff of 40 running seven projects, aided by a large group of volunteers.

Background
The decision to scale up was based on the dramatic increase in need for the services provided at the ASI clinic, and the expectation that the peak of the AIDS epidemic was still to come. By 1996 the organisation had grown and expanded its projects, but had no formal direction or strategic plan. There was at this stage a staff of 20, but the growth in demand for services was already taxing.

ASI decided to focus its efforts to scaling up counselling and treatment. Neither the government nor other NGOs were providing this sort of comprehensive approach in a clinical and community setting. But in order to ensure that the level of care would be sustained and expanded to meet the rising need, it would be important to establish alliances with other groups.

Scaling up would require additional trained staff to counsel and treat patients and expanded physical space for the clinic itself.

Objectives and activities
The objectives of the scaling up programme were to:
• Expand and improve the physical space and increase the staff available for treatment and counselling.
• Extend services to children and babies.
• Improve monitoring and evaluation of the various areas within the programme
• Establish alliances with other organisations to ensure uniform quality of treatment and service.
• Develop stronger relationships with the community and people living with AIDS.
• Establish alliances with the government to ensure funding and sustainability of the project.

The programme was conceived as part of a five-year strategic plan beginning in January 1997.

Resources and timeframe
ASI had grown dramatically in both size and number of projects since it began in 1987, but had not developed a formal direction or strategic plan to guide future growth. With assistance from the Dutch government, ASI hired an external consultant to help develop the five-year plan for restructuring and expansion.

The Dutch government offered funding for the first three years to support core staff in this time of strategic planning. This money was not intended to fund any of the specific scaling up efforts, but to allow ASI time to search for sources of long term, sustainable revenue.

The process of obtaining funding has been very difficult. While there is strong national support for the programme, there is not always money available. Because of this, the process has been slow, and often stalled. Local donations did enable ASI to open a new and larger clinic in July 1997, but there was no money to hire additional staff to handle the increase in patients until January 1998. During this lapse, the staff was overworked and stressed.

Community support is essential to the programme. When a local family that was respected in the community lost a son to AIDS, they contributed financially to the programme, but more importantly, their support helped remove barriers within the larger community.

Outputs/outcomes
Initially, the clinic expected to see an average 15% yearly increase in-patients. This was the case for the first two years, but the year 2000 has already produced an increase of over 100%. The huge increase is partly due to expanded availability of services at the new clinic, including a new counselling programme, but probably more a result of an accelerated phase of the epidemic in Guatemala. The anticipation of a dramatic increase in affected populations was a key reason for the scaling up.

Since the strategic plan is still underway, evaluation is limited. There is an important initiative just beginning to form a strategic alliance with the Ministry of Health to establish a national AIDS unit to treat people from all over the country. There is also a movement to pass a national AIDS law.

Internal organisational implications
The primary difficulty in the scaling up process was the need to balance the limited funds and resources between existing programmes and developmental projects. The scaling up process required more technological equipment, specialised staff for evaluation, and other specialised staff not contemplated in the original plan. Although some funding was provided, there was still a drain on resources. ASI absorbed these additional costs, but it caused some tension within the organisation.

While the staff understood the need to expand the programme and was supportive of the effort, it also felt that resources were being diverted from existing programmes. Directors held several sessions with the entire staff to keep the line of communication open.

Volunteers were very supportive of the expansion. A special research programme was established within the clinic, recruiting university students to assist professional staff while working on their medical studies. These volunteers were especially valuable in collecting data for monitoring and evaluation.

The effort to form strategic alliances with other groups, particularly organisations of people living with HIV/AIDS has helped improve the quality and impact of care.

Evaluation
The monitoring of the scaling up process was not a formal process, although reviews were conducted twice a year to evaluate the progress. Before the scaling up process, the clinic recorded basic demographic information as well as medical records on treatment.

A more comprehensive evaluation of the scaling up process was difficult because no funding was available for the process itself. As previously mentioned, there were periods of rapid growth and periods of no growth due to erratic funding. This made it difficult to assess the overall progress at the early stages.

In January 2000, additional staff was hired specifically to work on evaluation.

Lessons learned
The scaling up process for ASI was essential. The caseload was increasing so rapidly that either the capacity grew or the programme would have no longer been functional.

It was clear from the beginning that forming strategic alliances with other NGOs and government organisations was essential to the success of the expansion.

The initial process of scaling up, in which the clinic space was physically expanded, went well because ASI already had a good relationship with the hospital where the clinic was located.

Community support was invaluable. The acceptance of the programme by prominent families and community leaders greatly increased general support.

The strategic alliances with NGOs have worked well, but the process has been slow. The division of labour and the shared search for funding from a limited pool of resources will always be a strain on NGO alliance relationships. Initially, some organisations saw no need for working together, but as the scope of the epidemic has increased, the importance of alliances has become clearer.

In countries with limited resources, strategic alliances are a key factor in the success of scaling up any programme. The search for funding placed an ongoing burden on administrative staff. An alliance with the government is expected to allow for a steady income and the survival of the programme.

The involvement of government has been slow, but as the number of people affected continues to increase sharply, the Ministry of Health has begun to look for organisations with experience for help.

Organisations of people living with HIV/AIDS must be involved in any scaling up programme from the beginning. This generates trust and a sense of empowerment within the community and makes people more willing to participate in education and prevention programmes, and to accept treatment.

This small, ongoing scaling up process in the ASI treatment and counselling programme has allowed the organisation to gain experience and plan more effectively for the future.

Source: A Question of Scale
This is an extract from A Question of Scale: The challenge of expanding the impact of non-governmental organisations’ HIV/AIDS efforts in developing countries,
by Jocelyn DeJong, published by the Horizons Project of the Population Council with the International HIV/AIDS Alliance in 2001. To view the whole report follow this link.

To download, complete with graphics, in pdf format (which requires Adobe Acrobat software to read it) follow this link (file size 1.43 Mbytes).