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Finally, after 20 years, the world has acknowledged the impact of HIV. The Declaration of Commitment, agreed by 189 nations at the UN General Assembly Special Session on HIV/AIDS in June, may not have any immediate effect, but it should begin to change attitudes and policies and perhaps increase resources. This may result in increased pressure on successful community-based organizations (CBOs) and NGOs to expand their work. At present, in the words of Noerine Kaleeba from UNAIDS, programmes that are effectively carrying out HIV care, prevention and impact alleviation are islands of excellence in a sea of inaction. The challenge now is to expand their work, link up the islands and banish the sea.

Over the past year, the Alliance has held a series of workshops with NGOs and CBOs to explore the process and challenges of such expansion. Also, in partnership with Horizons, the Alliance held an international seminar on Scaling up NGO action on HIV/AIDS.

Discussions identified several interlinked elements, each essential to achieve expanded impact:

• People who are vulnerable to HIV and those who are key to the dynamics of an epidemic must be the focus of HIV programmes. This varies at different stages of an epidemic and in different places.

• Given the right focus, programmes need to increase their coverage to reach the maximum number of people.

• The work needs to be of sufficient quality and appropriate to the local context.

• Programmes must be sustainable. Organisations may concentrate on increasing any one of coverage, quality or sustainability. Each is worth striving for in itself, but it is when all are taken into account – and when the focus is right – that a programme can significantly increase its long-term impact. Even in ideal circumstances, with a carefully planned scale-up strategy in place, expansion may lead to tensions between these elements – for example, as coverage increases, quality may temporarily drop.

Evaluation has a role in ensuring that it is the successful programmes that are selected and scaled up. Leadership and solid administrative systems are important to ensure that capacity exists to carry through and sustain expansion. The scale-up process needs to be community-led and if possible to take place within a favourable political climate.

No single definition of scale up was agreed, but one important lesson emerged. CBOs are effective because they are small-scale and close to their constituents, whereas Governments, donors and national NGOs may think of scaling up in terms of reaching a defined target – perhaps a whole region or a country. CBOs cannot go to scale in this way, but they can increase the impact of what they do within their smaller arena. The need is for more, not necessarily bigger, local work. At the same time, services and mass information do need to reach out to whole populations. The answer may be for the small islands of community-based work to multiply and join up, while national level programmes bridge the sea by expanding essential services, providing technical support and creating a favourable policy environment.

Scaling up Anti-AIDS Clubs in Zambia
Viewpoint: Dixter Kaluba, Programme Officer, Family Health Trust (FHT), Zambia

There was a very real need in Zambia to scale up prevention activities with young people. Our scale-up strategy involved decentralising support from our central office and strengthening the peer education approach. In this way, we hoped to address some of the problems which we had identified; for example: Clubs closing down when adult facilitators left, Club members feeling demotivated by adult-led activities, the difficulties in providing adequate support to an increasing number of Clubs from one central office, and the lack of community participation and training opportunities for young people.

Previously, FHT had provided direct support to adult facilitators from one central office. Through the decentralised system, we appointed community members as
regional co-ordinators to train and support zone co-ordinators. These are usually school leavers who are responsible for training club leaders and members, and for monitoring and supporting all the Clubs in their zone.

Decentralising the support system to the Clubs has improved our effectiveness through more intensive outreach work and by using participatory activities to
encourage young people to respond to the challenges of HIV/AIDS. We have also addressed the issue of sustainability through the production of an activity manual which gives ideas for Club activities and by training a large number of
community peer educators (Regional and Zone Co-ordinators). In addition, the Clubs are now self-sustaining as they are established and kept running by motivated young people.

Through this approach, we have achieved the following results:

• An increased community participation and sense of ownership – e.g. traditional leaders have started to participate in the Clubs.

• A wider variety of educational activities for young people.

• An increased participation by young people – e.g. in producing Information, Education and Communication (IEC) materials (‘Happy, Healthy and Safe’ Manual and Anti-AIDS Club Newsletter) and in the formation of new clubs.

• An increase in demand for condoms.

• An increase in the number of young people seeking treatment for sexually transmitted infections.

Some of the difficulties that we have encountered during the scale up process include:

• Zone Co-ordinators having to travel long distances by bicycle to visit different Clubs.

• Retaining members when there are no financial benefits.

• High gender imbalance and difficulty in recruiting girls.

We are addressing these issues and are hopeful that this approach will lead to many more effective Anti-AIDS Clubs.

Family Health Trust (FHT) is a Zambian NGO which contributes to the prevention of
HIV/AIDS and provides care and support to those infected and affected. Over the past few years, FHT has been scaling up by decentralising their Anti-AIDS Clubs in order to contribute to HIV prevention among young people in Zambia aged between 10 and 25. There are currently 2,561 registered Anti-AIDS Clubs, with over 70,000 members.

Factors that help or hinder scale up
At the Community Lessons, Global Learning workshops in India and Zambia, participants brainstormed the factors that help or hinder the scale up of HIV/AIDS initiatives. The following provides a summary of the two sets of conclusions:

What helps scale up: Internal Factors

• Supportive political environment.

• Provision of funds and donations.

• Provision of materials and services.

• Adequate networking and reciprocal support.

• Community support for the programme.

• Enough volunteers.

• Adequate health services

What helps scale up: External factors

• Previous experience in programmes.

• A clear, shared vision.

• Clear guidelines and good planning.

• Skilled and diverse staff that are committed and work as a team.

• Involvement of influential people.

• Strong leadership.

• The ability to say "no".

• Good relations with donors, and a regular flow of funds.

• Accountability and transparency of the organization and programmes.

What hinders scale up: Internal Factors

• Lack of funding, plus inflexibility and changing priorities of donors.

• Political interference and corruption.

• Community resistance.

• Poor dissemination of information about government policies/funding.

• Rivalry among NGOs.

• Conflicting priorities.

• Confusion around project ownership.

What hinders scale up: External Factors

• Donor dependence and limited resources.

• Lack of planning and co-ordination.

• Lack of clear goals and vision.

• Staff burn out.

• Poor monitoring of the programme.

• Conflicting messages and information.

• Changing organisational priorities.

• Restructuring and changes in leadership.

• Lack of dedicated and skilled staff, including those with technical expertise.

Key lessons learned from workshops in Ecuador, Morocco, India and Zambia on scaling up community action on HIV/AIDS

• Successful scale up is not just about numbers. As well as increasing coverage, it also requires attention to the focus, quality, sustainability and impact of programmes. Each element is vital in its own right, but even more so in its symbiotic relationship to the others. For example, a programme is unlikely to have significant impact if it lacks coverage and quality.

• Not all NGOs/CBOs should scale up. If groups are new, have limited current or potential capacity, or are experiencing internal or external instability, it is a wise and acceptable decision to say "no". In such cases, these groups can make their most valuable contribution to HIV/AIDS by continuing and strengthening their existing efforts.

• Ongoing community participation – including the involvement of PLHA – is vital for maintaining the integrity, quality and sustainability of scale-up work.

§ Scale up may involve short and long-term "trade offs" in areas such as quality of programme work and accountability to communities. NGOs/CBOs must be realistic about the potential repercussions of such work, and each one should define its own "minimum standards" against which to assess whether compromises are acceptable.

• Scale up is not a one-off, overnight event. It is a process that continues and is improved over time.

News update
Zimbabwe and Mozambique
The Alliance has formed a partnership with Family AIDS Caring Trust (FACT) in Zimbabwe to expand the scale and quality of technical support to NGOs and CBOs supporting community responses to HIV/AIDS in East and Southern Africa. The Alliance will also support FACT to build the capacity of Kubatsirana, a local NGO in Mozambique, to develop the scope of its own capacity and the quality of the technical support that it gives to its local CBO partners.

Nigeria
Following an assessment and consultation visit earlier in the year, the Alliance has established a partnership with the Nigeria Network on Ethics, Law, HIV/AIDS Prevention, Support and Care (NNELA) in Ibadan. The partnership will initially focus on training and technical support on home-based care and support activities, with a commitment to addressing other programmatic areas such as prevention, impact mitigation, and organisational development for CBOs as the initiative expands.

Ukraine
The Alliance has recruited programmatic and administrative staff to a new field office in Kiev. Work to support local NGOs and to set up a national information centre is now fully underway. A participatory community assessment workshop was held and 10 NGOs completed assessments with injecting drug users and sex workers. The first issue of a newsletter and a new web site, www.aidsalliance.kiev.ua, have been launched.

Regional Workshop on Injecting Drug Use in Asia
Building on lessons learned at last year's regional workshop on injecting drug use in Asia, the Alliance has held a follow-up workshop to build skills in designing and carrying out participatory assessments with injecting drug users. Held in Thailand, participants from Asia, Eastern Europe and West Africa took part in the workshop.

New Partnership with NAM
The Alliance has started to work with NAM, Europe's leading provider of HIV and AIDS information, to make HIV and AIDS information resources widely available and to increase the proportion of NAM's award winning web site aidsmap.com, which is useful in Africa, Asia, Eastern Europe and Latin America.

Policy
The Alliance and several of its partner organisations fully participated in the NGO consultation before and during the United Nations General Assembly Special session (UNGASS) on HIV/AIDS. The Alliance produced position papers on seven key aspects of HIV/AIDS policy to contribute to these consultations.

Alliance secretariat has moved
The Alliance secretariat has moved from London to Brighton, on the south coast of England. Please see our new contact details at the top right hand corner of this page.

Supporters
Alliance linking organizations continue to increase and diversify their funding support. A number of donors have recently begun to support Alliance partners for the first time, including the Japan Social Development Fund, AusAid, the British Embassy (Cambodia) and the Packard Foundation, which has recently granted $1.58 million over three years to PHANSuP in the Philippines.

In Bangladesh, USAID will now channel support to HASAB through the country office of Family Health International (FHI) rather than through the Alliance, with the Alliance continuing to provide technical support.

Internationally, the Alliance has recently renewed grant agreements with several of its ongoing donors, and funding has been secured for the first time from Comic Relief's Children's Promise initiative. A very successful Supporters’ Meeting was convened in the UK in early June; a report of proceedings is available from the Alliance secretariat.

Publications and Resources
Expanding community action on HIV/AIDS -NGO/ CBO strategies for scaling-up A report of lessons learned on scale up from the third year of the “Community Lessons, Global Learning” project is available electronically and in print from the Alliance and to download from www.aidsmap.com.

The following policy statements are also available electronically and in print:

• The importance of prevention – prevention must be central to the global response to AIDS.

• People living with HIV/AIDS – people living with HIV/AIDS must be supported to respond to the epidemic.

• Access to treatment – access to treatment for people with HIV must be dramatically improved.

• Children affected by HIV/AIDS – urgent support is needed for families and communities which include children affected by HIV/AIDS.

• Linking prevention and care – prevention, care and impact mitigation initiatives must all be scaled up and better integrated.

• Building partnerships – partnerships must be genuine to optimise the strengths of all those involved in the response to HIV/AIDS.

• Additional funding needed – massive additional investment is required to support the global response to HIV/AIDS.

Manual de Instrumentos Prácticos para Construir Relaciones Externas A Mexican adaptation of the Pathways to Partnerships toolkit is available from the Alliance's Mexican linking organisation, Colectivo Sol.ww

Alliance News

Number 11, August 2001

• Expanding community action on HIV/AIDS