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15. Special Challenges in Scaling Up HIV/AIDS Efforts
   Last updated: 16.08.02
Donor Funding
Many of the above critiques have also been levelled at NGOs active within HIV/AIDS. Although it is recognised, for example, that an increased level of donor support is necessary to increase the scale of operations, many have pointed to the damage created by a sudden influx of large amounts of donor funding.34 If sufficient reflection has not taken place internally regarding the strategic use of the funds - such as in a thoughtful process of preparing for scaling up – the influx of money is likely to diminish creative effort within the organisation and may jeopardise the effectiveness of its programmes. Moreover, as organisations increasingly compete in chasing donor funds, this is likely to create jealousies and rivalries with other organisations that should be natural allies in efforts to increase the impact on HIV/AIDS.

33 S. White (1999) “NGOs, Civil Society and the State in Bangladesh: the politics of representing the poor” Development and Change, Vol. 30, No. 2. 34 The dynamics created in PWHA organisations by greater donor funds being made available are particularly complex given the fact of the intrinsic conflict of interest where staff and beneficiaries belong to the same group (O’Malley et al 1996).

Some have noted that receiving an increasing scale of funds – particularly if available through official channels negotiated with the state - may make NGOs less critical of government policy, and inclined to shift away from an advocacy role (Sittitrai 1994). This has been observed in Australia, for example, where the increasing official recognition of AIDS councils has prompted their expansion into large service-delivery organisations whose autonomy from the state is increasingly questioned.35

35 Geoffrey Woolcock and Dennis Altman cited in O’Malley et al 1996. This has also been found in Brazil where the fact that a World Bank project brought an increasing scale of funding to NGOs made them less critical of government policy (according to Richard Parker and Jane Galvao as cited by Chris Castle, personal communication).

A less analysed feature of increased levels of donor support is how it may affect the local reputation of the organisation and community perceptions of its activities. Hyden and Lanegran (1991), in a “political mapping” of the AIDS epidemic in East Africa, argue that HIV/AIDS agenda setting within Africa has been overly dominated by international donors and Northern NGOs. According to them, this reinforces the perception among Africans of AIDS as foreign and reflecting outsider determination to prove that AIDS originated in Africa. Others within the HIV/AIDS sector, such as Decosas 36 have argued that donor agencies have played too prominent a role in influencing HIV management in southern Africa.

36 J. Decosas (1994) “The answer to AIDS lies in united commitment” AIDS Analysis Africa 5,1,3-4 quoted in Campbell and Williams 1999

A more recent concern has emerged that with increased commitment for donor organisations to work on HIV/AIDS and to increase their budgetary allocations to it, particularly since the Durban conference, there is a growing competition among donors for NGOs to support.37 There is also concern that in the desire to spend these larger budgets, donors seek to commit larger amounts of money at one time to non-governmental organisations. This has thereby increased attention to issues of NGO absorptive capacity. There is a risk that donor funding may proceed at levels beyond the existing absorptive capacity of NGOs, and thus stifle their existing good efforts. To avoid such problems, clearly NGOs themselves need to refine tools for assessing their own capacity. 38 The ultimate risk is that the need of donor agencies to disburse larger amounts of money to local organisations may distort their original objectives or capacities. As Decosas, who has voiced this fear and is critical of the preoccupation of international organisations with scaling up, notes: “A scaled up local response is no longer a local response, it becomes something else.” (Decosas 2000).

37 Chris Castle, personal communication

38 A report commissioned by USAID on measuring absorptive capacity within the population and health field (Brown, Lafond and Macintyre 2000) notes that the available literature suggests that efforts to measure the outcomes of capacity building are at a very early stages of development, although there is a wealth of experience described in the grey literature. The availability to developing country organisations of the latter literature, which documents, for example, a range of measures for self-assessment of organisational capacity, is however unclear.

Cultural and Political Resistance
One of the greatest obstacles to HIV/AIDS prevention is the extent of stigma surrounding the disease, with its attendant association with “illicit” or “immoral” sex, fatal disease and death (Herek 1999; Gilmore and Somerville1994). While cultural perceptions of the origin of the disease vary, such stigma has been identified across cultures (Goldin 1994).39 Stigma itself creates resistance to people in the general population recognising their own high personal levels of risk behaviour, since they feel the fact that they do not belong to a stigmatised “high risk group” makes them safe.

39 See for example Nnko ’98 on Tanzania

Given the sensitivity and stigma surrounding HIV/AIDS it is not amenable to the simpler strategies of scaling up, such as the process which Myers refers to as explosion, which is more characteristic of, for example, immunisation or literacy campaigns. While in some relatively non-controversial areas such as blood safety, “explosion” may be possible as an approach, in most aspects a slower pace and less visible nature of expansion may be more appropriate in HIV/AIDS. The stigma surrounding HIV/AIDS may make it difficult, moreover, to mobilise sufficient demand for scaled up services, rendering it particularly important to communicate the aims of the intervention as scaling up proceeds. In some cases where stigma is particularly strong, NGOs have learned that it may be more appropriate to promote services for the general population, rather than making it explicit that it is for people with HIV/AIDS – such as, for example, expanding access to care for the chronically ill.40 Similarly, peer educators working in HIV/AIDS may prefer to be seen as community health educators because of the stigma associated with HIV/AIDS (Horizons 2000b).

40 Chris Castle, personal communication

As stated above, while NGOs are able to deal with stigmatised groups, often they are able to do so because they operate on a small enough scale to be non-threatening on religious, cultural or political grounds. Yet if they choose to expand their activities with such groups (strategy 1), they may perversely increase the latter’s vulnerability to state repression or social prejudice. If their scaling up strategy aims to catalyse other organisations (strategy 2) and they choose deliberately to work with government, they may well confront political and legal restrictions in working with these groups. In Egypt, for example, the National AIDS Programme cannot work with sex workers, since commercial sex work is illegal there.41 Similarly, in Pakistan, homosexuality is against the law.

41 Professional experience of the author in Egypt, 1992-99

At a political level, governments may be reluctant to draw national or international attention to HIV/AIDS because of the fear of tarnishing their national image or a detrimental effect on crucial economic sectors such as tourism. Moreover, they may be averse to the kinds of alliances and networking among NGOs which scaling up necessitates. This depends on the degree to which the political climate is one that discourages or encourages the role of NGOs generally, and what legislation exists regarding oversight of their activities.

Greater Visibility
In many respects, increasing the scale of HIV/AIDS activities may bring greater visibility or prominence to specific organisations but perhaps more importantly to their constituencies. Depending on the political and social context in which NGOs operate, this may be beneficial or detrimental. In cases where it increases stigma associated with HIV/AIDS or risks increasing discrimination against marginal social groups – such as sex workers or drug-users, this visibility may have very negative effects. By contrast, in the case of some low-prevalence settings, such as Ecuador and the Philippines, this may be a necessary step to increase public awareness and give groups involve greater negotiating power (Margarita Quevedo, KIMIRINA and Ruthie Libatique, PHANSuP, Horizons/Alliance Seminar).

Promoting “Community Participation”/Facilitating Community Response
The foregoing has argued for the need for careful attention to be paid to participatory processes which give beneficiaries a clear voice in defining directions and activities of HIV/AIDS organisations, and involving affected communities and individuals in the design of interventions. These needs are made all the more acute by the scaling up process. Yet, those who are members of the “community” of interest in HIV/AIDS may well be diffuse, not organised along geographic or social lines, and may themselves resist efforts to promote their “participation.” Asthana and Oostvogels (1996), in a cogent analysis of the obstacles to community participation in HIV prevention among female sex workers in Chennai (formerly Madras), India, for example, found that sex workers there came from diverse social backgrounds, worked in a range of establishments and had varied access to support structures. Their ability to organise is therefore “limited by the fact that they are locked into unequal power relationships with brothel-owners, madams and pimps and often too isolated and powerless to act individually or collectively” (ibid.: 133). Yet, in the end the women prefer to rely on such patrons – no matter how unequal the relationship – because it is a “least risk strategy in extremely precarious circumstances” (ibid.: 146).

Incorporating Diversity
Scaling up HIV/AIDS programmes beyond the borders of particular communities inevitably brings organisations into contact with a greater diversity of “beneficiaries” whether in terms of social class or background, educational levels or income (Smith and Colvin 2000). Given how social attitudes about HIV/AIDS are often closely tied to such background variables,42 developing messages and approaches that are suitable to this new diversity is challenging. Where initial activities against HIV/AIDS began in primarily urban, middle-class movements, for example, efforts need to be made to transcend this narrow focus. This constraint would argue for a phased programme of implementation, rather than a sudden expansion or explosion, to give the organisation time to adapt to and learn from the diverse settings and how best to work with constituencies from a wider range of socio-economic backgrounds.

42 For example, Klouda (1995) cites a study in Abidjan which found that 26% of patients from the lowest socio-economic group reported having been rejected, blamed or isolated by their families as opposed to none in the highest socio-economic group (Ingegno, A. et al “AIDS patients in Abidjan: social dynamics and care process” Int. Conf. AIDS 6-11 June, 1993 Abstract No. PO-D20-4014).

The Pace of Scaling Up
The rapid spread of the HIV/AIDS epidemic calls for urgent measures to expand the scale of all activities to stem the progress of the epidemic. It is clear that the challenge for NGOs in HIV/AIDS is to find a balance between moving at an appropriate pace to mobilise demand and adapt the intervention to local social contexts and often highly stigmatised groups, while at the same time generating enough momentum and sufficient political commitment to sustain the effort. The pace of expansion, however, is not usually set by internal or micro-level concerns alone, but rather by the overall context in which NGOs operate. For example, as argued in the discussion of motivations, often the rapid spread of the epidemic, or economic and political factors can play a key role in calling for a more rapid response in face of growing need. On a positive note, however, where there is a surge in political commitment at the national level, or internationally, as was the case following the International Conference on AIDS in Durban in July 2000, the pace of scaling up is likely to quicken. As will be discussed below, however, there are dangers that higher levels of international funding for HIV/AIDS may dictate the pace of expansion at a rate faster than the capacity of NGOs to sustain that activity.

Risk of Failure
Perhaps the most poignant risk in scaling up HIV/AIDS programmes is that of failure, with disappointed expectations on the part of beneficiaries, NGO staff and funding institutions. As Avina notes, failed expansion has been the reason for the demise of many NGOs (Avina 1993). It is with this risk in mind that sound choices need to be made by organisations deciding to scale up whether they have the capacity to do so, the programmatic maturity and sufficient funding to sustain a greater scale of intervention. Some of these internal dimensions will now be addressed.

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).