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International HIV/AIDS Alliance, 1993-2000
   Last updated: 16.08.02
by Jeff O’Malley
The development of the International HIV/AIDS Alliance since its foundation in 1993 illustrates a continual process of scaling up through a number of the strategies identified in the paper. For this reason, and also because different approaches to HIV are also illustrated through the Alliance experience, this substantial case study is included as an appendix in its own right.

The Alliance was formally established in December 1993 and its first staff person took up responsibilities in January 1994. The initiative had begun in 1991 with a series of discussions among a group of individuals from northern donor agencies about how to increase support to, and therefore the coverage of, community responses to AIDS in developing countries. These initial discussions were followed by a series of needs assessments, project design activities, and two country-level pilot projects leading to a proposal for support to create "The International Alliance Supporting Community Action on AIDS" (to be renamed the "International HIV/AIDS Alliance"). The following quotation from the original proposal for support captures much of the thinking that informed the Alliance's creation:

"Effective HIV/AIDS prevention, care and community support programmes require changes to individual attitudes and sexual behaviour which can only be brought about by a sustained and massive mobilisation of communities which, whilst small individually, together add up to a large-scale response. To effect this, financial and technical resources have to be made available at village and neighbourhood level on a vast scale and used to supplement existing community resources to implement programmes in education, condom distribution and STD prevention, and in innovative care and community support programmes. The intention of the International Alliance Supporting Community Action on AIDS (IASCAA), is to support non-governmental organisations to implement both small- and large-scale interventions which can have a rapid and significant impact on the spread and effects of AIDS." [Cliff Lenton, "The International Alliance Supporting Community Action on AIDS (IASCAA) Proposal for Support", 12 November 1993, pp 3 -4.]

The Alliance was established with a clear strategy to act as a catalyst and to support action on HIV/AIDS by other organisations - NGOs and CBOs operating locally in developing countries. The core function was to identify or establish national mechanisms (later to be called "linking organisations") and provide them with technical and financial support. These linking organisations would support NGOs already working on HIV/AIDS in their country to scale up; catalyse new groups to begin responding to AIDS for the first time; and support both those new to HIV/AIDS and those already engaged through providing organisational and technical support. This reflected a commitment to community action by NGOs and CBOs, (later changed to community action by local NGOs and CBOs), rather than a commitment to expanding any particular type of programme or intervention.

From the Alliance's inception it was anticipated it would support the expansion of these other organisations through "organisational expansion", as well as through "mainstreaming in development" .

["The roles of the national mechanisms will be to help organizations already engaged in HIV/AIDS … to expand and scale up their work…and to reach out to a wide variety of private sector groups not yet engaged in the prevention and management of the epidemic", Lenton, op cit, p. 3.]

The key target adopted for the first three years was to establish and support "NGO support mechanisms" in 14 countries with an anticipated funding level of approximately US$21 million of unrestricted funds. These would be channelled to a central fund, approximately 80% of which would be invested in programme expenditure, for which the Alliance itself would develop technical criteria. The funding would cover international and local technical support, linking organisation running costs and grants to NGOs and CBOs. Costs needed to provide technical support from an international base were estimated, but no projection was made of the relative cost of supporting linking organisations vis-à-vis investment in local implementation of prevention, care and impact mitigation activities. No targets were articulated concerning either the number of people to be reached, or the quality of activities to be supported.

The needs for organisational and technical support to linking organisations were far greater than initially anticipated. At first this was because the Alliance's model of supporting an indigenous organisation to raise funds, disburse funds and provide technical support was unusual not just in HIV/AIDS work, but development work overall. Support needs then increased with increasing pressure on performance and deviation from the original programme design (more donor restrictions requiring more complicated finance and programme systems, more detailed requirements for monitoring and evaluation data, more emphasis on programme quality in addition to quantity).

The need for in-country technical support was recognised when the Alliance was established, but local technical support costs were not clearly differentiated from the costs of in-country service delivery. In the Alliance's initial business plan, no explicit acknowledgement was made of the very clear cost difference between supporting successful and capable organisations to expand, as opposed to convincing and supporting organisations with very little HIV/AIDS experience to begin, improve and expand work on HIV/AIDS.

Just over 10% of the anticipated funding was committed at the start of the programme. With further fundraising (a task not initially anticipated in the Alliance's business plan), an additional $9 million was raised over the initial three-year period. About 60% of this was restricted, with the majority of the restrictions requiring marked deviations from the Alliance's original plans. From the perspective of the Alliance's Executive Director, the Alliance's most significant mistake in its first two years was its failure to convene stakeholders to agree a new business plan and new targets in light of real commitments and restrictions rather than original projections and hopes.

Evolution of the Alliance's approaches
The start-up period: Alliance development from 1994 to 1996

By mid 1996, the Alliance had worked with local partners to conduct national assessments of the NGO/CBO sector’s response to HIV/AIDS, and the potential to expand and improve that response, in ten countries: Philippines, Bangladesh, Sri Lanka, Pakistan, Morocco, Senegal, Burkina Faso, Tanzania, Mozambique and Ecuador. To some degree this mix of countries reflected a strategy to test the Alliance’s approach in both low and high prevalence settings and in countries with weaker and stronger NGO sectors; to establish a programme base in each of Asia, Africa and Latin America; and to avoid particularly complex settings such as India or Brazil in the start-up period. To a great degree, however, the mix of countries reflected donor restrictions on how funds could be used, including geographical restrictions which dictated, for example, the choice of countries in West Africa and the exclusion of the Caribbean. Funds covered assessments in Tanzania and Mozambique, but were insufficient for programme development. Programme development was suspended in Pakistan because there was no suitable in-country partner and the national government did not strongly support the initiative. The Alliance’s first seven country programmes were thus developed in Ecuador, Senegal, Burkina Faso, Morocco, Sri Lanka, Bangladesh and the Philippines.

The Alliance’s scale-up strategy hinged on two levels of action,
• Community-level responses to prevention, care and (to very limited degree) alleviating the impact of HIV/AIDS
• National-level NGO/CBO support.

Community responses were developed in more than 50 sites. In each of these, a participatory community assessment was undertaken, leading to project design and community mobilisation. In general, these assessments were highly successful, both as a prelude to successful project design and as a means to cultivate community ownership. Following assessment, programme and project design included peer education programmes for young people, participatory prevention (largely adapted from the “Stepping Stones” programme of participatory community discussion groups), and interactive awareness raising activities. Self-help groups were also created and supported.

During 1994-1997, the Alliance also had limited experience of supporting pilot projects in areas such as peer education in particularly vulnerable populations (men who have sex with men, sex workers) NGO based sexual health delivery, NGO based care and support services and intensive community development with key vulnerable populations. In the start-up period, there was little or no involvement in a number of other possible programme areas related to HIV/AIDS, such as condom social marketing, in-patient care, mass media harm reduction activities and blood safety programmes.

National level NGO/CBO support included assessments of national NGO/CBO sector strengths and weaknesses, the establishment and management of grant making facilities, the development of a limited range of methodologies to identify and respond to NGO/CBO technical support needs, and partnership building and external relations for partner organisations. Little or no attention was paid in this period to some other NGO/CBO support functions, such as fundraising, either for implementing NGOs/CBOs or linking organisations: development of skills in building partnerships; policy analysis and advocacy; formal operations research; epidemiological surveillance; production and/or dissemination of training materials and educational materials; or maintenance, development and promotion of resource centres or libraries.

After two years of operation a donor-organised external evaluation team reviewed the Alliance’s programme. The evaluation’s broad conclusions were positive:

"The Mission's unequivocal answer to the central question of the Evaluation is therefore that if donors wish to continue to develop the civil society response to the epidemic in the developing world, they should continue to fund the Alliance." ["Joint Donor Evaluation of the International HIV/AIDS Alliance", October 1996, p. 5.]

By 1996, 86% of the Alliance's expenditure, a higher proportion than originally anticipated, was allocated to technical assistance and funding for local programmes. In a total of seven countries, 220 organisations had received financial and technical support for HIV/AIDS work, 200 of which were general health or development organisations rather than HIV/AIDS groups. Although this scale of activity was obviously less than initially projected, most stakeholders recognised that it was a significant achievement, particularly in view of the reduced funding.

It was acknowledged that it was too early and too difficult to assess the impact of this work on the epidemic, but both the Alliance's own evaluation and other evaluations indicated that promising approaches were being promulgated at a community level, as reflected in these citations from USAID and EU documents:

"When there is uncertainty about what contextual changes are appropriate or most significant, a valid strategy is to enable the people who are closest to the problem to decide, to experiment with different approaches, and to see what works. This is the methodological approach taken by the International HIV/AIDS Alliance, which offers one example of how to develop contextual interventions in HIV/AIDS prevention and care. ["Process evaluation of the AIDS Technical Support Project" of USAID, July 1996, pp 79 -80.]

Despite these overall positive assessments, however, the Alliance's external evaluation and other analyses and discussions pointed out some problems and controversies with the Alliance's approach and performance. The three most significant were:

• Concern that a greater proportion of expenditure than anticipated was absorbed in support and operational costs of linking organisations, and that in some cases this exceeded the funds allocated to local NGOs and CBOs to carry out activities in prevention, care and impact mitigation. Different stakeholders cited different reasons for this. The Alliance external evaluation team believed that the Alliance had over-emphasised NGO support capacity as a goal, rather than seeing such capacity as a delivery cost. The Alliance secretariat countered that developing such capacity was a legitimate goal in itself, and that, as country programmes inevitably have a certain level of fixed costs, under-funding would increase the proportion of expenditure on "NGO support" vis-à-vis implementation.

• The international donor landscape had evolved considerably over the Alliance's first two years, with significant changes including a strong trend to devolving funding decisions to missions or delegations based in developing countries; the elimination of many HIV/AIDS specific budgets following the Cairo Conference consensus on integrated approaches to sexual and reproductive health; and the creation of UNAIDS to replace WHO/GPA. Together, these changes considerably challenged the Alliance's structure and model.

• It was unlikely that the Alliance itself could increase its operating budget significantly. Nevertheless, there was strong pressure to pay more attention to quality and impact of interventions and responses, and a strong desire for the Alliance to play an increased role in learning and influencing others.

Transition phase: 1997
A new scale-up strategy was developed by the Alliance and endorsed by its donors in February 1997. Key features of this new strategy included:
• An emphasis on the Alliance’s technical rather than financial contributions to scaling up community responses to AIDS. This led to a strategy of influencing existing initiatives (that already had secure funding) rather than supporting new programmes.
• An emphasis on catalysing rather than directly sustaining expanded responses, and reducing support over time.
• A commitment to experiment with new methodologies – development and testing of tools, operations research, advocacy - to influence practice indirectly rather than directly.
• New goalposts for performance measurement: mobilising new responses; improving the quality of responses; building capacity of NGOs and NGO support organisations; and learning and influencing.
[“The International HIV/AIDS Alliance Proposal for Support 1997 – 1999”, 28 January 1997]

The new strategy was based on the implicit assumption that, rather than being concerned about finding a global mechanism to deliver funds to community level, donors and multilateral agencies now had a growing appreciation of the Alliance’s knowledge and experience of leveraging funds and improving community responses to HIV/AIDS. The Alliance’s value-added was thus to be in learning, influencing and leveraging rather than funding.

With reference again to de Jong’s proposed typology in this publication, the Alliance’s post-1997 strategy depended strongly on “diffusion” approaches and explicitly introduced “influencing policy/legislation”. Commitment was maintained to “catalysing other organisations”, but with the emphasis on “catalysing” rather than “supporting in an ongoing manner”. This distinction suggests that de Jong’s “Strategy 2: Catalysing Other Organisations” might usefully be separated into two distinct strategies.

Scaling Up: 1997-2000
The Alliance’s original design was informed by needs assessments, consultations and pilot projects with key developing country partners. In contrast, the strategies adopted in February 1997 to scale up impact were the result of external evaluation processes and extensive consultations with donors.

There was no formal or informal consultation with developing country partners, who almost certainly would have expressed concern about the implications. Linking organisations were informed of the Alliance’s new goals and strategies and were required to change some of their own approaches to monitoring and evaluation but most key linking organisation staff and volunteers did not contribute to the shift in strategy and perhaps never fully understood it.

Depending on one’s organisational perspective, the Alliance’s strategic shift in 1997 could be represented as “more with less” or “less with more”. For donors, by and large, the strategy offered “more with less”: more countries influenced, more NGOs and CBOs influenced, more tangible products such as toolkits and operations research findings. For the Alliance’s existing partners, the opposite held true: the Alliance secretariat and its budget grew, while funding for any particular country programme tended to remain steady or declined. Steady or declining funds from the Alliance accompanied increasing pressures: to implement particular kinds of activities with particular populations; to pay much more attention to strengthening quality and evaluation; to document and market success-stories; and to fundraise.

In 1998, within a year of adopting the new strategy, one of the Alliance’s largest donors (USAID) introduced a new requirement for funding – to measure the number of people being reached. Although relatively straightforward, the measurement was at odds with the explicit goals of the new strategy and introduced conceptual difficulties to performance measurement and “ownership” (People reached with services financed by the Alliance? People reached by organisations influenced by the Alliance? People reached effectively or people reached at all?) More positively, despite redesigning the Alliance's overall strategy to increasing impact at low cost, donor funding increased considerably from 1997 to 2000.

During this period the Alliance actively discouraged investment in broad public awareness raising, programmes designed to serve the general public, and income generation activities. In contrast, there was a growing awareness of the importance of concurrent community action to address supply of services and commodities for prevention and care and to stimulate demand for these services, while taking account of context issues such as gender roles and stigma. More support was therefore channelled into following up discussion groups with outreach programmes, home care initiatives which integrated prevention and referrals, and the promotion of the involvement of people with HIV/AIDS. Gender issues such as violence against women and creating a sense of responsibility among men and boys, and STI service delivery including condom promotion were all emphasised. Peer education and community development activities with marginalized communities key to the dynamics of the epidemic were encouraged.
New pilot activities included harm reduction and prevention of sexual transmission with people who inject drugs, community mobilisation linked to voluntary testing and counselling, and a response to the needs of orphans and vulnerable children. Links between care, prevention and impact alleviation began to be emphasised, and community based advocacy took a higher priority.

There have been some seemingly contradictory pressures on the Alliance from its donors – pressure to influence linking organisations to influence NGOs and CBOs to reach more people, pressure to increase quality of activities at the community level, and pressure to increase “influencing” and “advocacy” functions based on community lessons. The tension between these goals had resulted in many positive changes and an increase in the Alliance’s impact. Most notably at the level of community implementation, a healthy balance has been found between intensive prevention and care work with populations key to epidemic dynamics, broader awareness activities, and partnerships with governments to reach larger numbers of vulnerable people, especially young people.

Results to date
From 1994 to 1999, mostly after the strategic shift in 1997, the Alliance raised approximately $23 million from international donors to support its work. The target funding for its first three years was thus achieved over six years. Donors also provided $5 - $6 million directly to linking organisations or partner organisations. By the end of 2000, the Alliance had worked with NGOs or CBOs from 25 countries, and was supporting ongoing NGO/CBO support programmes in 13 countries. The linking organisations had provided technical and financial support to over 1,520 projects implemented by over 950 different NGOs and CBOs, about 85% of which were not AIDS groups – in fact about 70% of them became intensively involved in AIDS for the first time through the Alliance’s support. Many of the linking organisations also became key institutions influencing their national policy environments.

The Alliance has not had a comprehensive external evaluation since 1996, but evaluations of particular initiatives and ongoing monitoring point to the achievements of its current hybrid approach:
• In 1999 alone, almost 1.5 million people were beneficiaries of prevention, care and/or impact-mitigation programmes or services supported by the Alliance, at a cost of about US$2.50 per person. Over 325,000 volunteers, mostly young people, were involved in intensive activities as "peer educators" or “care givers” in their communities. It is estimated that over 8 million people were reached in 1999 through Alliance-supported mass media and IEC initiatives.
• In depth evaluations of particular initiatives show these programmes as making a real difference in people’s lives.

• An evaluation of a home care programme in Cambodia in early 2000 concluded, “It is reducing the suffering of people living with HIV/AIDS (PLHA) and improving the quality of their lives and the lives of their families and caregivers; it is increasing understanding of HIV/AIDS and reducing discrimination against PLHA in the community; it is helping to empower some of the poorest and most disadvantaged individuals and families in the community”.
• An evaluation of prevention activities in Senegal in 2000 concluded, “ANCS has achieved remarkable results with relatively modest means …ANCS has contributed significantly to the HIV prevention and care response in Senegal”.

Perhaps most notably, the Alliance's shift in strategy in 1997 allowed it to maintain (and even expand to some degree) the development and support of in-country NGO support systems which in turn assist local NGOs and CBOs which in turn organise and facilitate prevention, care and impact-mitigation responses. These activities, however, are no longer the sole or even primary criteria against which the Alliance's performance is measured.

Evolving ideas about scaling up
The Alliance was established within a rhetoric of "scaling up community responses to AIDS". What did that mean to different stakeholders? If more attention had been paid to the phrase, more contradictions in approach amongst and within different sets of stakeholders would have been identified. There was a broad agreement at the time that "scaling up" meant doing more, and in particular having NGOs and CBOs do more. There was relatively little explicit discussion at the time amongst NGO/CBO actors - or their supporters - of population-level impact, of priorities amongst different countries, of priorities amongst different technical approaches, or of how priorities might change at different phases of the epidemic. All of these are now understood as key issues.

In 1991 and 1992, many donors were concerned about investing available HIV/AIDS funds through the "multi - bi" channels of WHO/GPA, and were looking for a new mechanism to absorb and disburse resources. Although this situation had already started to change by the time of the Alliance's formal establishment in late 1993, it deeply informed the logic of the Alliance's creation. It is important to note that now, years later, a number of donor agencies seem to be once again concluding that scaling up means spending more money at community level. Hopefully some lessons have been learned.

In addition to Northern donors, the other key set of stakeholders involved in the Alliance's establishment were (mostly Southern) NGO and CBO activists. Amongst the most vocal and visible actors in the community response to AIDS, there was already some genuine debate in the early 1990s about what to do and how to do it. Key features of the debate at the time included pressure from community groups for more attention to care as opposed to a singular focus on prevention; more attention to marginalised populations and in particular their human rights; and debate about the relative merits of "AIDS-focused" versus "integrated" responses. NGOs and CBOs also wanted a larger share of the available resources for HIV/AIDS work, in particular vis-à-vis investments in national AIDS programmes. More recently, a similar consensus has emerged amongst many local NGO and CBO activists, but vis-à-vis international NGOs rather than vis-à-vis national AIDS programmes. Then, as now, it was rare to find individual NGOs or CBOs making a case for different types of response (for example, condom promotion versus youth-abstinence clubs), or between different levels of response (for example, community-level services versus national awareness campaigns), or between different types of actors (for example, national NGOs versus national government agencies). Part of the Alliance's function has been to engender reflection and debate on these issues at a national level, although consensus on such priorities among NGOs and CBOs is probably unlikely to be reached.

In retrospect, one of the most striking elements of the discourse around the Alliance's creation was the focus on the non-governmental sector, differentiated from the government sector, as opposed to, for example, community and district responses differentiated from national or regional responses. Consciously or unconsciously, the Alliance brought together a set of donors who were looking to move beyond WHO/GPA and its support to National AIDS Programmes (governmental, health-focused rather than multisectoral, and largely policy-orientated rather than operational), with NGOs and CBOs looking to access more resources for their operations. (The original design of the Alliance did not differentiate between local CBOs or NGOs and international NGOs - this was an added emphasis introduced by the Alliance's Trustees and management in 1994.) Key stakeholders largely missing from the Alliance's original design included people living with HIV themselves, as well as national AIDS programme managers and national governments.

Over the period since the Alliance's establishment, perceptions of "good practice" have been constantly evolving, informed by practice and experience as well as shifting theoretical paradigms. Some generalisations can be made about how "scaling up" is viewed at different levels.

About 1,000 participatory community assessments were conducted with Alliance support from 1994 to 2000. Depending on the priorities of the Alliance partner and the technical and strategic biases of technical support providers, assessment methodologies varied: focused just on needs, or also on resources and hopes; embracing a broad range of community priorities, or focusing on HIV in the context of gender, sexuality and sexual health; working with key populations such as sex workers, or working with neighbourhoods or villages as a whole. [Many of these experiences and methodologies have now been consolidated into a recommended approach by the Alliance, in the toolkit “Getting Started”, 2001.] In general, however, individuals and communities tend to see HIV prevention as a medium- or long-term issue: in low prevalence countries, a threat that may emerge in years to come, or in higher-prevalence countries, an important issue for a new generation. A wide range of other issues have a higher short-term profile, from helping young people get jobs to reducing gender violence to maintaining or achieving clean water supplies. The most dominant theme emerging from prevention-focused assessments has therefore been scoping out rather than scaling up – that is, linking HIV to other contextual and development issues, such as gender relations and poverty.

The active involvement of people living with HIV in the process of participatory community assessment and programme design helps to keep results focused on both care needs and the reality of vulnerability to infection. Recently, affected communities have drawn attention to the importance of equity in access to treatment, especially equity with Northern communities’ access to anti-retroviral treatment. The stark reality of how few people with HIV have access to any care at all creates a tremendous pressure for scaling up action on AIDS.

From an organisational perspective, community based associations and smaller community-focused NGOs may share an interest in "scoping out" but are often also interested in reaching more people through expanding their own activities, especially to nearby communities, districts or neighbourhoods. Despite this commonality, however, larger NGOs - local, national and international - have quite diverse priorities for increased action on HIV/AIDS, embracing the full range of scale up strategies identified in de Jong's paper. It is rare indeed for an NGO of any size to conclude that it is doing enough, or that it has enough resources.

Not surprisingly, national AIDS programmes (like NGOs) also share the perception that action on HIV/AIDS needs to be scaled up, and the belief that this requires additional resources, but their priorities for scaling up NGO and CBO action vary. Some place a strong priority on an institutional and geographic diversification of support to NGOs while maintaining a belief in "targeted approaches" for particular populations. Others very clearly identify priority districts for increased action as well as functionally supporting particular NGOs to grow in expertise, coverage and resources. Still others appear to argue for increased support to and engagement of community groups, while challenging strong roles for national or international NGOs. These distinctions typically reflect both legitimate differences in priorities in particular places (regarding how and why to scale up action on AIDS), and inevitable differences in politics both within NGO sectors, and between NGOs and governments.

Donor thinking on "scaling up" has also evolved. Rhetoric about "leveraging other resources" or “ensuring sustainability” is still a common feature in much donor discourse – this may be influenced by political concerns. There is also a great deal of recent interest and commitment to having an impact on the epidemic rather than simply "learning" and "piloting" initiatives. Although some donors like DFID place more emphasis on partnerships with governments and others like USAID on partnerships with NGOs, most are more conscious than in the past of how their investments fit in to other activities to achieve a critical mass of coverage. In addition to paying attention to measuring the gross numbers of people reached, there is a strong trend to pay attention to quality, synergies between different approaches, and the potential of partnerships, as well as to impact. This highlights differences of opinion on issues such as the relative merits of rapidly rolling out a limited number of key interventions as opposed to a “programme approach” emphasising a package of responses; the relative priority of working in low versus high prevalence countries; and the relative merits of concentrating limited resources on "core transmitters" versus reaching a new generation of vulnerable young people.

The Alliance’s unusual structure of a “two tier umbrella programme” has meant that tensions and synergies between local actors (implementing CBOs and NGOs) and national actors (linking organisations and their donors) are almost always mirrored between national actors (linking organisations) and international actors (the Alliance secretariat and its donors). In almost all cases, the Alliance and its partners have achieved their most notable results in the balance or compromise between competing pressures.

One key tension has been between “community led” and “evidence based” - or “bottom up” and “top down” - approaches. The Alliance began with a strong bias towards community led approaches, but through a combination of donor pressure and internal decisions, began to promote more aggressively what it perceived as good practice (including good practice in being community led!). The strongest and most sustainable initiatives are rooted in processes such as participatory community assessment and national-level decision-making about priorities and strategies, informed by “expert” advice on matters such as key populations for epidemic dynamics, and effective strategies. Balancing these perspectives and processes is slower and more intensive than either a straightforward replication of standard interventions or a laissez-faire approach of funding what the community wants to do.

Another tension has been between “targeted” and “general population” approaches, or “intensive and expensive” approaches versus “broad and cheap”.
A key lesson from the Alliance’s programming experience has been the importance of paying attention to key populations for epidemic dynamics, especially in concentrated epidemics in low prevalence countries. This does not mean ignoring other populations; it is important to recognise that one community impinges on another’s choices and options, as well as to respond to multiple and shifting community identities and behaviour patterns. This again points to a view of scaling up that synthesises intensive services and programmes with and for key populations, and working more cheaply with broader communities for awareness, against stigma and to ensure referrals.

Finally there has been a clear tension for the Alliance between intensifying programmes in a smaller number of countries and having some involvement in a larger number of countries and regions. Funding pressures have had more influence than programme strategy on this. It seems reasonable to speculate that costs per person reached would be significantly lower had the Alliance worked in fewer countries and languages with the same level of overall funding. The politics and processes of organisational growth and fundraising are central to any strategy to achieve more impact and it is difficult to say whether the Alliance could have achieved more with a more focused strategy, or if its attempts to respond to perceived donor pressures and funding availability were essential to its survival and growth, and to its ability to contribute overall to the scale-up process.

Table 1: Main community responses supported by the Alliance in the start- up phase, 1994- 96
Table format: Activity // With whom? // Outcomes // Comments

Participatory community assessment // CBOs at community level // •led to project and programme design, •sensitised key populations/ stakeholders, •began community mobilisation process // Generally very successful – led to successful project design and “community ownership”

Peer education programmes for young people // Young people in and out of school // •Large numbers of young people trained in HIV basics, prevention and referral for further information and services •Condoms demonstrated // Successfully promoted and sustained behaviour change in peer educators but little impact beyond awareness raising on wider groups on young people

Participatory discussion groups // Members of specific communities, in age and gender- specific discussion groups, culminating in common discussion group // •Debates and action planning on HIV/ AIDS •Change in attitude and behaviour at community level // Highly effective but expensive and requires extensive training/ skills building

Linking these groups to community development activities // As above // •Income generation •Adult literacy // Relevance and impact not clear

Interactive awareness raising activities // General population: activities such as neighbourhood meetings, World AIDS Day rallies, red ribbon folding, pamphlet distribution // •Increased awareness of HIV // From 1997, scepticism about the value, but more recently, recognition of importance where awareness is low, to include young people and to create a favourable environment for more focused activities

Creation of self- help groups for people with HIV // People with HIV // •Peer psychosocial support •Treatment activism •Income generation •Succession planning activities for children // “With this disease, the people who suffer the most are the poorest… If we don’t get together in groups and find help and medicines , we don’t stand a chance”, person with HIV, member of EUDES in Ecuador

Table 2: Pilot Projects 1994-97
Table format: Activity // With whom?// Outcomes // Comments

Peer education with specially vulnerable populations // Men who have sex with men Sex workers // •Behaviour change // If run well, particularly cost effective

NGO based sexual health service delivery and HIV testing and counselling // Sex workers, Attenders at reproductive health/MCH clinics // •Pre and post- test counselling provided •STI counselling, diagnosis and treatment •Referrals to care facilities // Particularly effective with specialist government services eg Philippines services for sex workers; less effective with NGO-provided reproductive health or maternal/child health clinics in lower prevalence countries

NGO based care and support services // 400 people with AIDS and 5,000 family members and close associates // •Home care including basic medical care and prevention activities // Cost about $20 per person with AIDS per month including start-up costs, with falling costs in later years

Intensive community development with key vulnerable populations // Sex workers, adolescent men who have sex with men, transvestites // •community organisation •building self-esteem // Examples are IWAG- Davao on the Philippines and FAES in Ecuador.

Changes in 1997- 2000 are outlined in the text. These included more emphasis care and support through home care, and a greater attention to the integration of care and support, prevention and impact mitigation. Pilot projects began to emphasise work with key vulnerable populations, the introduction of harm reduction concepts community mobilisation linked to children’s issues and to voluntary testing and counselling, and initiatives against stigma and discrimination. In Zambia, the Alliance joined a wide range of other partners in the “Zambia Integrated Health Project” a multi- issue health initiative.

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).