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6. Scaling Up as a Process
   Last updated: 16.08.02
 
As important as it is to be clear about the end objectives of scaling up, the process of reaching these aims is significant both programmatically and for the organisation involved. The great strengths of NGO activity to date in HIV/AIDS prevention have been the relationships of trust they have inspired among their constituencies and the processes of participatory decision-making they encourage, both of which have enabled them to address sensitive issues. As Fowler (1991) has written of development NGOs in general, their comparative advantage lies more in the quality of their relationships than in the size of resources they command.

Approaches to scaling up expounded by the private sector, such as franchising and developing particular pilot models of which exact replicas are planted in starkly different contexts, have been very influential in development circles (Wazir and van Odenhoven 1998). Yet they may not be appropriate strategies for the field of HIV/AIDS, where the importance of factoring in local specificities, and the need for attention to processes and values is pre-eminent. As Myers notes, the challenge is to think about scale in a way that “allows a qualitative, decentralised and participatory approach to that goal, as contrasted with the more quantitative, centralised and imposed approach that seems to predominate” (Myers 1992). Nonetheless, the opposite extreme of arguing that programmes are so context-specific as to make lessons or replication to other areas impossible, an approach that Wazir and van Odenhoven (1998) refer to as “contextualist”, is also unhelpful. There is much that can be learned from small-scale efforts that is of larger relevance and applicability.

Examples of successful scaling up efforts of NGOs with clear impact suggest that some degree of distinctiveness and integrity of process needs to be sacrificed in the interest of reaching a greater scale. Both the Programme Support Group in Zimbabwe and the AIDS Support Organisation (TASO) in Uganda, for instance, illustrate that the development of standardised approaches with enough flexibility to allow for diversity among different communities can be highly effective. The prevention and mitigation efforts of the Programme Support Group share a common approach by training community volunteers through the use of modules, manuals and structured participatory approaches. As they describe it: “[Both prevention and mitigation] work with community volunteers to deliver large-scale, economical, locally relevant services that increase community response capacity (Appendix A, p. 44 PSG case study).” The organisation is exceptional in its rigorous attention to results. In one area, for example, they were able to demonstrate that Bulawayo condom use in sex work rose from 18% at outset to 72% within 2 years (p. 49 case study). While, particularly at the beginning, early partnerships “resent the loss of attention and uniqueness as scaling up proceeds” this resistance seems to wane as clear indications of the success of this approach emerges. PSG has grown from a small-scale effort based on a research project to a regional organisation operating in three Southern African countries.

Similarly, TASO helps local community-based organisations to develop counselling and clinical services for those with HIV/AIDS, thus leading to a proliferation of “TASO-like” services each of which are tailored to specific communities. (see TASO report on page 39, Section ii).

If scaling up, then, is conceived as a process occurring over time, objectives of the exercise may vary according to, for example, the different stages or level of the epidemic. At low levels of epidemic, when infection may be more restricted to certain social groups, different strategies may be called for than when the epidemic is more generalised within the population at large. For example, more “targeted” interventions can prevent the spread of HIV into the “general” population. Where HIV/AIDS is widespread, however, there needs to be a relatively high level of coverage within the general population in order to have the same degree of impact (although an incremental increase in coverage may have a significant relative impact).12 This is illustrated further in a diagram drawn by a small group at the Horizons/Alliance Seminar and replicated below in Figure 2. Thus, as discussed further in section ii below, the target groups of programmes are likely to change over time.

12 I am grateful to Helen Parry of the International HIV/AIDS Alliance for clarifying this point in her comments on this publication.

Figure 2 - The Relationship Between Coverage and Impact According to Level of HIV Prevalence

Source - From a group exercise at the Horizons/Alliance Seminar

[The figure, not reproduced here, compares two different points on a line of rising HIV prevalence. For each, there is a square of equal size representing impact. A triangle represents coverage, and is shown as being far larger where the prevalence is higher. A circle represents sustainability, and is larger where the prevalence is lower, smaller where it is higher - representing the greater challenge of sustaining a response where the epidemic is causing most problems. The caption, summing up the message is: "At high prevalence, one needs high coverage to have impact".]

Modifying the objectives of programmes as scaling up proceeds may also be necessitated by changes in the political context. Two case studies presented at the Horizons/Alliance Seminar emphasised the importance of being able to respond to unanticipated changes in the policy environment during the scaling up process. For example, changes in the donor landscape in HIV/AIDS conditioned the strategy adopted by the International HIV/AIDS Alliance (Alliance case-study, appendix c). And in India, the course of scaling up the Healthy Highways project to reduce transmission among truck workers and their sexual partners was affected by both policy changes within the main funding organisation, the UK Department for International Development (DFID), as well as the desire of the Government of India to command greater direction over HIV/AIDS activities (Robert Grose, DFID, Horizons/Alliance Seminar).

Objectives of scaling up may also change over time due to the internal situation of the organisation. One participant at the Horizons/Alliance Seminar noted that at some stages in the scaling up process there was actually a cutting back in order to strengthen programmes and prepare for expansion – thus an organisation may initially need to scale down in order to scale up (Shyamala Nataraj, SIAAP).13 It is not clear, however, whether this example is representative of other NGO experiences of scaling up.

13 At this stage, SIAAP – which was operating with 40 employees, cut their staff down to only 6, prior to a subsequent “re-scaling” (Shyamala Nataraj, SIAAP, Horizons/Alliance Seminar).

A Dynamic Relationship Between Prevention, Care and Mitigation
As noted above, HIV/AIDS is distinctive among health problems in its dynamic relationship between preventing its incidence, and supporting, caring for and treating those infected and affected by it. If the premise of scaling up initiatives is to build the capacity of individuals and communities to respond to the epidemic, many would argue that the starting point should be problems identified by the constituencies that NGOs work with. In many contexts, such community initiatives are more likely to emerge to care for and support those affected by HIV/AIDS such as in the area of orphan support. Children may often represent the most visible victims of the epidemic to whom humanitarian efforts are readily addressed. There is often more resistance to working with marginalised social groups who may be subject to prejudiced views that they are somehow “morally responsible” for the epidemic. Thus – although care may provide the catalyst for a broader approach to HIV/AIDS, scaling up prevention programmes may require more external motivation than that of care programmes. For example, church-based programmes across Africa have emerged to care for orphans and support families affected by the epidemic (Foster n.d.), but many find prevention messages addressing condoms and sexual behaviour more sensitive.

In some cases, however, community initiatives have emerged in the area of prevention and have subsequently moved into care. For example, the Anti-AIDS Clubs that the Family Health Trust has supported in Zambia moved from awareness raising and prevention in schools to working with orphans. According to Dixter Kaluba, this has helped to familiarise youth with problems associated with the epidemic and thus “young people don’t feel the epidemic is so distant”. Elsewhere, in low prevalence settings, where HIV/AIDS is not visible to the majority of community members, it may be easier to stimulate community participation in prevention rather than care. This is the case in Ecuador, for example, according to the director of KIMIRINA.

In Cambodia, a home-based care programme has provided a critical link between care, prevention and mitigation. Cambodia has one of the fastest growing epidemics in the world, yet faces a severe shortage of hospital beds, a poor population only a minority of whom can pay for prophylactic drug therapies and a high incidence of people living with HIV/AIDS (PLHA) having opportunistic infections (Wilkinson et al. 2000). Community leaders in Phnom Penh mentioned to an evaluation team, for example, that until the Home Care Team started visiting, people did not believe there was AIDS in their areas. The visits helped to increase knowledge about HIV/AIDS and understanding of preventive measures (Wilkinson et al. 2000).

Identifying and building on the appropriate strategy, however, may take a “trial and error” period of learning. As the founder of the South India AIDS Action Programme (SIAAP) aptly described: “It took SIAAP four years of sustained community-based interventions with women in prostitution, truckers, blind people and people with HIV/AIDS to understand the need to include community organisation, counselling and care as critical processes, perhaps even the first ones, in any community-based intervention that aimed at empowerment as a fundamental outcome.” (SIAAP case study Appendix A, p. 10) She drew a broader lesson of the importance of not singling out individual interventions for scaling up, without seeing the synergies between them. She illustrated her vision of these synergies and the importance of community organisation in figure 3.

Figure 3 - A Vision of the Shift from Linear to Integrated Programming

Source - Presentation by Shyamala Nataraj at the Horizons/Alliance Seminar

[This figure, not shown here, is split into two halves. On one side, "pre-1997" a straight horizontal line connects "health education", "condoms", "STDs", "counselling", "care" and "advocacy". On the other side, "post 1997", the same line is drawn into a circle with the addition of "community organisation" linking the different programmes together.]

Despite the evident synergies in scaling up prevention, care and mitigation efforts, in many contexts interventions in these areas may compete for resources. A recent World Bank report on costing the expansion of HIV/AIDS programmes in Africa notes, for example, that as HIV prevalence rises there are increasing costs associated with the burden of care. Therefore there will be greater tensions in allocating scarce resources between prevention and care interventions (World Bank 2000).

Scaling up From an Economist’s Perspective
Much of the economic analysis that has been applied to scaling up within the context of HIV/AIDS is premised on a public health perspective as outlined above and tends to focus on the large-scale delivery of services usually by governments or the private sector. As noted above, there is a dearth of costing analysis of NGO programmes and NGOs themselves often neglect to consider the cost implications of alternative strategies. Cost is defined as the value of resources used to provide a service, and the total cost of an intervention represents the cost of all inputs used, and varies with the number of people reached. The assumed impact on HIV/AIDS from an economist’s perspective is the output of an intervention, usually in terms of the number of people reached with a specific intervention. This makes it difficult to apply costing in areas where impact is defined more broadly and in more qualitative terms, and where the definition of scaling up is not solely based on increasing coverage, as outlined above.

Nevertheless, the concepts economists apply to assessing costs of scaling up can be applied in a variety of ways and thus are essential for those engaged in scaling up to understand. The following therefore presents a description from an economist’s point of view of the main questions relating to a determination of costs.14

14 We are grateful to Lilani Kumaranayake of the London School of Hygiene and Tropical Medicine for providing the material for this section.

There are a number of issues that come to the forefront when thinking about scaling up and costs from an institutional perspective. The organisational approach to increasing the number of people being reached will affect the consideration of costs. Increased coverage might be the result of expanding existing interventions to reach more people or it might mean creating similar new interventions, and then is referred to as replication of an intervention (Kumaranayake 2000). While both could increase coverage, the implications for costs are quite different.

A basic diagram of these relationships is provided in Fig. 4. The underlying notion behind the expansion of activities is that an organisation which is expanding its scale of activities will likely initially have decreasing average costs (or the cost per person reached). Beyond a certain point, continued expansion due both to organisational characteristics (e.g. need for more coordination etc) and characteristics of the groups being reached (e.g. less accessible) will mean increasing cost per person reached. Thus expansion of activities has been encouraged as a means of achieving economies of scale (and so improving the efficiency of delivering services). However, beyond a certain level of activity, continued expansion will lead to diseconomies of scale, and an increase in the average cost per person.

The curve below illustrates a typical short-run relationship between average cost (AC, or the total cost per person reached) and marginal costs (MC, or the change in total cost of reaching an additional person), hypothesised by economic theory. The AC curve refers to average costs and MC refers to marginal costs. The average cost is often thought to have a U-shaped relationship with respect to the level of output. This reflects the fact that at relatively low levels of activity (or scale), as the number of people being reached increases, average costs or the cost per person being reached decreases. However, at higher levels of activity (or scale) average costs are thought to increase reflecting the fact that one might need to add substantially more inputs in order to increase the number of people being reached. We see that marginal costs start to increase at lower levels of activity relative to average costs, reflecting that marginal costs will start to increase before average costs.

Figure 4 - Introduction to Economic Concepts of Cost and Scale (adapted from Kumaranayake 2000).

[This figure, not reproduced here, is a graph titled, "Relationship between average and marginal costs for a project". The Y axis is for cost ($) and the X axis is for Output (number of peole reached). The MC and AC curves are shown as U-shaped, with the minimum point of the AC curve representing the minimum average cost, setting the boundary between economies of scale, on the left, which increase to that point, and diseconomies of scale, which increase to the right. This is also the point where the marginal cost and the average cost will be the same, so the two curves intersect.]

When diseconomies of scale occur, that is when the cost per person reached actually increases as the project is expanded, cost reductions can be made by both reducing the scale of activity or replicating the project (on the more efficient smaller scale) in another location. Thus, from a cost perspective, both expanding current activities or replicating projects may be desirable, and is dependent on the actual cost-structure of the project, the location where it is operating, and the nature of the target population that it is trying to reach.

There is a dearth of evidence about the nature of costs as projects are replicated or expanded. This is particularly unfortunate given the degree to which costs vary according to a wide range of criteria related to motivation, organisational characteristics and geography among others. For example, a study looking at the replication of peer education interventions for HIV prevention among sex workers in Cameroon found that, even within the same country, there was a two to three-fold difference in average costs across different cities, and that the cost-effectiveness varied substantially. This reflected differences in project implementation, motivation of project staff, capacity of staff to reach target populations and differences in the sex worker populations across cities (Kumaranayake, Pepperall Goodman, et al 2000).

A second issue related to costs of scaling up activities lies in the nature of resources which are used in a project and which are directly paid for by an NGO. Financial costs represent actual expenditure on goods and services purchased. In a financial costing, costs are described in terms of how much money has been paid for the resources used. In order to ascertain the financial costs of a project we need to know the price and quantity of all the resources used, or alternatively the level of expenditure on these goods and services. In contrast, economic or opportunity costs recognise the cost of using resources that could have been productively used elsewhere. Thus, economic costs include the estimated value of goods or services for which there were no financial transactions (such as unpaid volunteer time), or when the price of the good did not reflect the cost of using it productively elsewhere (such as donated radio time) (Kumaranayake, Pepperall, Goodman et al 2000).

Financial costs are important when considering budgeting or cost-recovery within a project. However, they may not give a full picture of the overall resources used for an activity. Economic costs are particularly useful when considering the resources needed to replicate or to scale up existing activities, when it may not be possible to utilise similar donated or subsidised inputs. In this case, simply using financial costs as a guide to resource requirements for scaling up may seriously underestimate the resources required if a large proportion of inputs are provided for free, and if this proportion declines as activities are expanded or replicated.

Where activities have been delivered on a pilot or small scale, which is of particular relevance to NGOs, expansion or replication of activities may require significantly more resources than previously. This is both because of the ways in which additional services are delivered and the nature of what now has to be paid for (for example employing paid staff rather than enlisting volunteers).

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).