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9. A Proposed Typology of Scaling Up with Application to HIV/AIDS
   Last updated: 16.08.02
 
To our knowledge, however, there has been no such analysis of approaches or philosophies to scaling up specific to the HIV/AIDS sector. In an effort to distil the findings from the above analyses of scaling up development NGOs more generally to processes relevant to HIV/AIDS, the following framework has been developed (summarised below in Figure 6). Five different types of strategies are envisioned, which can be represented on a continuum along which the original organisation that initiates the scaling up effort becomes less and less involved. The continuum also presents a gradation of strategies that become increasingly abstract in nature, and it is thus difficult to measure their impact.

This typology does not represent evolution of organisations, and indeed they may employ several of these strategies simultaneously with different types of HIV/AIDS programmes as appropriate to particular time-periods, geographic areas or social groups.

Figure 6 - A Proposed Typology of Scaling Up in HIV/AIDS

Each strategy named here is followed by main objectives (Main) and type of organisation involved (Org).

Strategy 1: Organisational Expansion Strategy
Main: Diversify • geographical area / • social groups / • functions
Org: Initial organisational only

Strategy 2: Catalysing Role (a)
Main: expand range of services provided
Org: • Government (service) / • Private sector / • Other NGO / • CBOs

Strategy 3: Diffusion
Main: Spread • Concept / • Approach, or / • Technology
Org: Any

Strategy 4: Influencing policy
Main: Influencing policy climate
Org: • Government • Donors • NGOs

Strategy 5: Mainstreaming in Development
Main: Legitimise discussion of HIV/AIDS and sexuality broadly
Org: All development institutions

9.1 Strategy 1: Organisational Expansion
This category refers to the simplest form of scaling up activities, which reflects the effort of one organisation, rather than attempts to work with others. It entails increasing scale either by reaching a greater number of people, social groups or geographic areas, or expanding the functions or activity of the organisation. This may include, for example, developing a pilot project that is then expanded to a greater geographic area, or the opening of branches of the same organisation in different places.

Among the most famous examples of this first strategy is the Bangladesh Rural Advancement Committee (BRAC), which began in 1972 and is now one of the largest Southern NGOs with a staff of over 12,000, a budget of close to $23 million and reaching over 3 million people. BRAC has achieved this scale through careful expansion of both the types of activities it undertakes (diversifying from economic activity into child survival and women’s health for example) and by moving into different geographic regions of Bangladesh. According to one analysis of this scaling up process, quality was not sacrificed (Howes and Sattar in Edwards and Hulme 1992) perhaps owing to its careful process of experimenting through pilot projects, learning from them and then replicating them on a greater scale (Uvin 1995).

Extending to other population groups has been an explicit orientation of the scaling up objectives of a number of HIV/AIDS organisations. For example, Colectivo Sol, an NGO based in Mexico City, started by focusing its efforts towards self-identified gay men, but initiated educational programmes and other services for a wider group, including young people and other NGOs.19 Similarly, staff at ASI felt the need to extend their clinical services to children and babies. Their expansion of the programme was driven by increased demand for their services, projections of an impending rapid increase in the epidemic, and their perception that they either had to close or expand to cope with their rising case load. Similarly, the Family Health Trust has successfully reached out-of-school youth through its scaling up process, although it is much more costly and difficult to gain access to these young people than those in school.

19 Chris Castle, personal communication.

9.2 Strategy 2: Catalysing Other Organisations

a) Technically and b) Financially

This strategy refers to efforts on the part of one organisation to work deliberately with other organisations either within the same sector or different sectors to influence the nature or scope of their service provision. This could entail developing relationships with government (particularly in terms of their service provision, not policy), the private sector 20 or perhaps most usually, with other NGOs. For example, an organisation may develop a model, which the government is then persuaded to take over.

20 For example, the Thai Business Coalition, an NGO, aims to increase the scale of impact by increasing the involvement of business leaders in workplace AIDS programmes and to guide the development of AIDS policies in business settings (Sittitrai 1994).

One successful example of this strategy is the strengthening of counselling capacity in government services with the involvement of SIAAP. Existing government STD facilities were not attracting patients – particularly women -- due to lack of a receptive atmosphere. SIAAP saw an opportunity to introduce counselling to break communication barriers between doctors and patients. In this case, government clearly saw the advantage of potentially increasing demand for their services. An arrangement was agreed whereby the government pays the salaries of counsellors who are trained and supervised by SIAAP. In the latter’s judgement, the effort has been successful, and they have received requests from governments in neighbouring states for similar assistance.

Alternatively, an NGO may persuade another NGO to adopt an HIV/AIDS programme within its health or developmental activities.21 This category would encompass the work of NGO support organisations, which see their main contribution as offering technical, financial and social support to smaller organisations. This may entail providing expertise or guidance based on greater experience in HIV/AIDS, or may be of a more organisational development nature. An explicit part of KANCO’s mandate, for example, is to assist member organisations in strategic planning, organisational development and financial accounting.

21 This has also been referred to as “grafting” whereby, for example, a programme for adolescents is added to existing services which failed to reach adolescents (Smith and Colvin 2000) and could also apply to links with governmental services

In some cases, such organisations may begin as direct service providers but either begin by or move subsequently into supporting other organisations financially.22 Such efforts can be hampered by unequal power relations between the more professional-oriented NGOs offering assistance in capacity-building and programme design and the organisations receiving such support, in terms of access to finance, information and differential input into setting the agenda for the programme. SIAAP in South India, for example, at one stage began to support other NGOs financially but found it changed the nature of the relationship between the respective organisations and then restricted its support to technical issues. Nonetheless, where careful attention is paid to redressing such imbalances and where credit for success is fairly given, the results can be extremely positive.

22 Other examples of such types of organisations include TASO and SIAAP.

The experience of KIMIRINA was almost the opposite to that of SIAAP in that when they only provided technical support the commitment to HIV/AIDS was relatively weak (Margarita Quevedo, personal communication). They found that even with large organisations with significant budgets, having an earmarked budget for HIV/AIDS, even if modest, generates a higher level of commitment. In their view, only once an organisation has a high level of awareness and strong commitment will technical support be enough.

The International HIV/AIDS Alliance employs this strategy at an international level. It sees its broad mandate as scaling up community response to HIV/AIDS internationally - working through “linking organisations” which it supports both financially and technically. These organisations in turn reach out and support local NGOs in their settings technically, organisationally and through exchange of information and sharing experience within and between countries.

A number of organisations provide technical support to other organisations by arranging for exchange visits, both within a country or internationally. This approach is critical to the Program Support Group’s training to community volunteers in Southern Africa, for example.

HIV/AIDS prevention efforts may be most effective if integrated into existing infrastructures which already operate at a large scale across a range of sectors and thus NGOs may seek to “catalyse” those existing services to address HIV/AIDS. Indeed, seeking ways of combining HIV/AIDS interventions with delivery in other sectors, rather than focusing on scaling up individual HIV/AIDS interventions independently, may yield “economies of scope” whereby lower costs and greater efficiency are achieved than through separate delivery (Kumaranayake 2000). Yet, as Watts and Kumaranayake (1999) argue the potential for integrating HIV/AIDS programmes into other services, whether in education, reproductive health, family planning or sex education is often not fully exploited. They argue that in the short term, effective activities that can be scaled up quickly need to be identified, including using private sector (work places, unions) and informal networks involving religious and community groups. This could help increase the access of different social and geographical groups to specific activities (Watts and Kumaranayake 1999).

9.3 Strategy 3: Diffusion
The third type of strategy represents the effort to broaden impact by encouraging other organisations to adopt a particular concept, approach or technology. Diffusion is explicitly more abstract than previous strategies because it does not entail expanding one’s own or influencing others’ specific programmes or activities but rather spreading ideas or methodologies. Included among this set of strategies would be, for example, spreading the concept of peer education or community counselling or the promotion of male and female condoms (as technologies). This can entail either planned or spontaneous effort but by and large the initiating organisation is less directly involved in the implementation of the programme and works instead through influencing others. Outside the field of HIV/AIDS, this strategy has been very effective in promoting, for example, community-based rehabilitation approaches or reproductive health (particularly in influencing family planning organisations that previously provided highly vertical programmes).

The notion of community counselling in HIV/AIDS was foreign to India, for example, before SIAAP initiated a diffusion strategy to spread and legitimise the concept. Lacking expertise in India, they initially sought technical input from a number of international institutions. As a result of their efforts “SIAAP’s counselling programme has been acknowledged and appreciated by the established medical system and endorsed by the Indian government.” (Case study, p. 12).

At the international level, the Salvation Army’s HIV/AIDS programme seeks to help communities to cope with the epidemic, and facilitates exchange visits across regions and countries to share experience and in which “facilitation teams” explore key concepts related to the epidemic with local stakeholders. In so doing, the organisation has endeavoured to diffuse the concept of communities measuring their own change in terms of having greater willingness and capacity to address HIV/AIDS (Case study, p. 16).

The Family Health Trust has also used this strategy to diffuse the model of the Anti-AIDS clubs to other schools in other locations. And ASI, which was the only clinical service in Guatemala providing integrated services to PLHA, made an explicit part of their strategy for scaling up to influence other clinical services to incorporate a similar approach.

9.4 Strategy 4: Influencing Policy/Legislation
At a yet larger scale, organisations may seek to engage deliberately the policies or legislation of government or of influential donor organisations. They may do so via efforts to shape the public debate on a particular issue, such as for example through outreach to the media so as to increase the understanding of the social determinants of HIV/AIDS or its impact. Or, they may seek influence via coalition-building and knowledge exchange to increase the collective demands of civil society on the state within the arena of HIV/AIDS. For example, KANCO – a national network of NGOs, CBOs and religious organisations concerned about HIV/AIDS in Kenya, -aims both to complement government responses and to push for a more conducive policy environment. It provides capacity building to member organisations and operates as a clearing-house to provide accurate and up-to-date information on HIV/AIDS. Similarly, ASI and members of a co-ordinating body of 28 organisations in Guatemala have been lobbying for a more humane HIV/AIDS law, and their efforts bore fruit with the passing of that law in February 2000. And in the Philippines, an NGO coalition has lobbied for the full implementation of the existing HIV/AIDS law (Ruthie Libatique, PHANSuP, Horizons/Alliance Seminar). NGOs have also used this strategy in influencing governments and pharmaceutical companies by creating national, regional and international alliances or coalitions to lobby for price concessions and greater access to treatment.

Among the strategies thus far, this is the most explicitly political. Moreover, trying to influence policy or legislation may necessarily require a confrontational approach. For example, the organisation SIAAP began through efforts to obtain the release of HIV-positive women illegally imprisoned in South India, and it did so through legal challenges in the courts, as well as by raising awareness among the public at large (Shyamala Nataraj, SIAAP, Horizons/Alliance Seminar). Similarly, the fact that the social security system in Guatemala now offers care and treatment was achieved through lawsuits (Annie Hirschmann, ASI (AGPCS), Horizons/Alliance Seminar). A number of initiatives of scaling up harm reduction have also relied on legal strategies and efforts to keep the police at bay (Jeff O’Malley, HIV/AIDS Alliance, Horizons/Alliance Seminar).

Some organisations may not initially engage in advocacy activities when they start work, but advocacy may become an explicit part of the scaling up process over time as they encounter obstacles or particular opportunities or needs. For example, the International HIV/AIDS Alliance based in the UK began to find ways to influence donor policies. And KIMIRINA, after several years of existence focusing primarily on catalysing small community-based organisations, began to initiate some advocacy activities as it increased its scale of operations and established a more solid institutional base (Horizons/Alliance Seminar).

9.5 Strategy 5: Mainstreaming in Development
Related to yet going beyond the fourth set of strategies, is the effort to permeate all development sectors with concern for and attention to HIV/AIDS and its implications. The explicit objective of such strategies is to widen the narrowly sectoral approach to HIV/AIDS by engaging the decision-making bodies and organisations across relevant sectors as well as seeking channels of implementation beyond the health sector alone. More of a development focus to AIDS efforts may also encourage a greater public understanding of the social context that puts individuals at risk of HIV/AIDS, including poverty, lack of education, ill health and the less tangible and more hidden problems such as inequitable gender relations, including women’s economic dependence on men, poor self-esteem or lack of control over how and when sex (and conception) take place. For although one needs to change social norms more broadly to slow the spread of the disease, often the poorest communities are most affected by it.23

23 This was one of the conclusions of the UK NGO AIDS Consortium report 1996

NGOs focusing on AIDS often find themselves ill equipped to deal with this broader development context of the pandemic.24 Conversely, development NGOs often do not take on HIV/AIDS efforts because they see it as a health problem outside their own area of expertise, a problem affecting only particular individuals rather than communities as a whole, or they may lack the financial and technical resources to do so (Sittitrai 1994). This is not to say, however, that HIV/AIDS specific NGOs should be advised to take on development activities previously not in their mandate. A more effective strategy is likely to be influencing non-HIV/AIDS specific NGOs to address HIV/AIDS so that, in the words of Kevin Orr of the Alliance “they don’t make the same mistakes we did.”

24 The HIV/AIDS Alliance conducted participatory assessments in 1994-5 on the needs of local AIDS service NGOs in 12 developing countries, and found that: “The NGOs surveyed in most of the countries also cited the need for more action on the contextual (societal) factors which increase vulnerability to HIV, such as gender inequality.” (O’Malley et al 1996: 346).

The International HIV/AIDS Alliance has implicitly adopted this strategy in the majority of countries in which it works by choosing broad development organisations, rather than AIDS-specific organisations as linking organisations. Out of the 220 organisations the Alliance had supported by 1996, for example, 200 were general health or development organisations (Alliance Case study, Appendix C). However, although the Alliance found this strategy more effective, it notes that the associated costs of working with organisations not specialised in HIV/AIDS is often higher, at least initially. AMSED in Morocco, a development NGO, is an example of an Alliance linking organisation. It is in turn collaborating with income generating organisations because they are already mobilised and Morocco lacks organisations working in communities across the country which have expertise in HIV/AIDS. Finally, PACT (in collaboration with the Alliance) specifically helps NGOs involved neither in health nor HIV/AIDS to address AIDS in Ethiopia.

Such a strategy is not without criticism, however. Ainsworth and Teokul (2000) argue, for example, that in poor developing countries with high prevalence of HIV/AIDS, where resource constraints are most evident and state capacity weak, encouraging non-health ministries to address HIV/AIDS may be spreading resources too thinly and may not be cost-effective. “AIDS mortality may strike every sector of the economy; however, this does not necessarily imply that adding AIDS prevention and mitigation to every ministry’s programme will be a cost-effective way of reducing the epidemic.” They argue instead that a selective number of interventions should be scaled up to national level by governments and pursued vigorously for achievable outcomes. However, their argument emphasises governmental strategies and is not specifically applied to NGOs.25 Moreover, they do stress the importance of integrating HIV/AIDS into poverty reduction strategies.

25 Interestingly, the same article notes that: “In many instances, the tendency of international agencies to work through NGOs has the effect of marginalizing the government” (Ainsworth and Teokul, The Lancet, 2000 – p. 58).

It should be noted that any one organisation may engage in a number of the above strategies simultaneously, and there may be overlap between the various categories. Moreover, the staging of the continuum is not intended to imply a chronological progression, as individual organisations may, after assessing their own comparative advantage and their environment, decide that any one of these broad categories of scaling up may be the most appropriate place to start.

9.6 TASO: An Example of The Evolution of Scaling Up Strategies
The efforts of staff of The AIDS Support Organisation (TASO) in Uganda to increase the scale of its activities and to widen its impact could be represented as an evolution of scaling-up strategies as presented in this publication. Their changing strategies reflected their response to the rapidly expanding epidemic and evolving policy context, and therefore emerging needs in the external environment, as well as their own institutional learning of what strategies were effective and manageable.

TASO began in the late 1980s as a support group of people infected and affected by HIV/AIDS in Uganda which started meeting informally in 1987 (Kaleeba et al. 1997). It then grew into a formal voluntary organisation with a mission of “restoring hope and improving the quality of life of persons and community affected by HIV infection and disease.”

At its inception, TASO focused on sensitising health care personnel to the needs of people with HIV/AIDS and providing clinical services to those suffering from HIV/AIDS and counselling for HIV/AIDS clients and their families. Initial approaches to scaling up focused on strategy 1 above, organisational expansion, or what they refer to as “purposive duplication” (Case Study p. 3). By 1990, TASO had opened 7 centres in 7 out of 45 districts (Case Study).

Shortly after its inception, TASO staff realised that clinic services were insufficient and that they were incapable of responding to increased demand and were indeed risking creating a dependency on TASO services (Antivelink et al). In the early 1990s, the TASO Community Initiatives (TCI) were established after recognition of the need to help communities address HIV/AIDS at the local level. Initially piloted in a few places near Kampala, they were replicated to other sites including Entebbe, Jinja and Mbale (Antivelink et al. 1996).

By the end of 1993, TASO was operational in seven districts in Uganda and was providing counselling, medical care and social support to a cumulative number of over 22,000 people with HIV/AIDS and their families (Kaleeba et al. 1997). Nonetheless, despite this substantial expansion within 6 years, there was still continued demand for services and in 1996, TASO revised its scaling up strategy. TASO then assumed a catalyst role (strategy 2 above) in moving from direct service provision to facilitating capacity building of other organisations. Thus a network of “TASO-like” services were created after 1996, while TASO centres continued to run as “model HIV/AIDS care centres” The aim of the strategy was to develop local capacity in existing health centres to provide AIDS services medical care, counselling, FP/STD services, managerial capacity etc. Because TASO worked through local district committees, it was able to ensure that there was local commitment to the objectives of their organisation. This strategy meant that the effective impact of TASO extended well beyond those districts where TASO services were physically located and priority could be given to districts which lacked any type of HIV/AIDS related services.

TASO provided limited resources to “TASO like services” although their own costs were more than expected because of the unanticipated need for supervision on the part of TASO staff An extensive participatory evaluation in 1996 prompted a revising of several of their strategies for scaling up (see Antivelink et al. 1996 and Kaleeba et al 1997). Of the many lessons the organisation took from the participatory review was the fact that “HIV/AIDS is not the only issue or need in the community” (Antivelink et al 1996) and the importance of TASO linking with organisations addressing other development needs such as famine, the social and legal vulnerability of women – particularly widows -- and orphans, and income generation (strategy 5 above).

By 1998, TASO had worked in 66 communities and trained over 2,500 community volunteers. Significantly, by this time TASO was working with 41 organisations in partnerships (2 hospitals, 7 health centres, 32 CBOs).

Despite the tremendous success of this innovative approach, however, TASO staff recognise that it encountered a number of challenges in scaling up its activities many of which have been observed among other NGOs during scaling up. These include the difficulty of monitoring quality and quantity due to lack of complete or reliable data at least partly due to inadequate record keeping by volunteers and health workers. Their efforts were also constrained by the problem of volunteer drop out and irregular supplies of condoms and drugs. They also acknowledge the problems of having only a few trained counsellors covering a large geographic area. As with other efforts involving collaboration with public sector staff, there were also specific challenges, such as the additional work and responsibilities placed on the staff of district health facilities when there were no financial incentives attached. Moreover, high staff turnover rate at the local health units meant that there was a continual need for training of new staff.

This case study illustrates that at different points of the epidemic, and on the basis of experience accumulated by individual organisations, strategies for scaling up are likely to evolve significantly over time.

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).