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Expanding community action - 1 (introduction)
   Last updated: 29.06.02
1. Introduction to scaling-up
“HIV is about people. We are demanded to walk an extra mile every day …. and we are having to walk many extra miles.” - Cedric Fernandes, Sahara Center for Residential Care and Rehabilitation, India

As HIV/AIDS nears its third decade, the pandemic is spreading inexorably. According to UNAIDS, over 36 million people, 95% in developing countries, are already living with the virus and 16,000 new infections occur every day.

HIV/AIDS brings with it immense personal, social and developmental challenges against which individuals, organisations and sectors throughout the world have battled to respond. But not enough has been done. Many millions still lack the information and skills to protect themselves, and millions more, who are already infected or affected, lack adequate care and support.

Therefore, scaling-up - or “going to scale” or “widening impact” - is critical for all involved, from those carrying out grassroots projects to those developing international policies. It matters not just because more people need services, but also because many of the changes that are vital to support effective action on HIV/AIDS – for example, addressing gender roles and levels of stigma – must happen at a large, collective scale.

Participants at the workshop in India discussed the meaning of scale-up (see box) and the Alliance in partnership with Horizions is publishing a report “A Question of Scale: The challenge of expanding the impact of NGO programmes on HIV/AIDS in developing countries” in which the definitions of scale-up are explored further

Although the exact definition of scale up is debated, the need for NGOs/CBOs to pay more attention to scaling-up is clear and, largely, beyond question.

Therefore, this report focuses on five inter-linked questions which answered together guide an NGO or CBO in scaling-up its work.

  • How can we reach the key individuals and populations that most affect the of the epidemic in our community or country? In other words, have we thought through the focus of our programmes?


  • How can we ensure that our HIV/AIDS programmes reach the largest number of key people possible with the resources that we have? In other words, are our programmes as efficient as possible in terms of coverage?


  • How can we ensure that our HIV/AIDS programmes provide services that are appropriate for the populations that we work with and of a high standard? In other words, how can we ensure that our work is of sufficient quality?


  • How can we ensure that the quality and impact of our HIV/AIDS programmes, as well as our organisations, last? In other words, how can we ensure that our efforts are as sustainable as possible?


  • How can we ensure that our programmes really make a difference, in terms of HIV/AIDS prevention or care, among community members? In other words, how can we make sure that we are having a real impact?


In addition, it is also vital to consider the question:

  • How do focus, coverage, quality, sustainability and impact inter-relate? Indeed, while each of these five elements is important in its own right, its relationship to the others is crucial. For example, to have a significant impact on HIV/AIDS, programmes must focus on key individuals or groups that most affect epidemic dynamics, be of a high quality, achieve significant coverage and be sustainable. Only as whole do these elements add up to not just scale-up, but effective scale-up.


NGOs/CBOs have an important role to play in scaling-up, particularly in countries where governments have limited resources or commitment. They have the advantage of existing relationships with communities, combined with creative approaches. This gives them great potential not only to carry out scale-up work, but also to catalyse action among others - by sharing examples of proven strategies and frameworks.

In practice, however, many NGOs/CBOs have struggled to move beyond projects that are of high quality, cost and maintenance, but serve specific, small-scale populations. As the UNAIDS 2000 report concluded: “Action remains sporadic and patchy rather than comprehensive. “Boutique” projects may provide services for one or two communities, while large areas of the countryside have nothing. Many programmes have yet to become comprehensive in either geographical coverage or content.”

In one way, the rationale for NGOs/CBOs to scale-up is simple – to reach more people and to both prolong and improve the quality of more lives. However, as a strategic response to growing epidemics, scale-up is not just about increasing numbers at a local level. It is also about the need to address the broader social issues that affect HIV/AIDS and the response at a national level. These include cultural “norms,” administrative systems and the policy environment.

While the majority of concrete examples of scale-up come from “mainstream” health and development, a growing body of work is emerging from the field of HIV/AIDS. However, it remains largely undocumented and unanalysed. As a result, we face a situation whereby, as the Alliance/ Horizons publication outlines: “While tentative consensus is emerging over the importance of scaling-up, there is much less shared understanding of the contexts most conducive to scaling-up, the type of organisations or programmes appropriate to expand, the internal implications of scaling-up, how to define objectives, measure the impact of scaling-up and how these processes depend on and interact with the political and social environment.”

By sharing and analysing real life examples of scale-up among local NGOs/CBOs, the “Community Lessons, Global Learning” project aimed to contribute to this global debate, and help the Alliance and its partners focus more on moving beyond small-scale projects.

Definitions of scale up, India
During the “Community Lessons, Global Learning” workshop in India, participants worked in small groups to define scale-up in words and pictures. Examples of the results include:

“Scaling-up is the process of reaching out to a wider community through effectively adapting existing programmes or organisations to meet changing needs.”

“We scale-up in order to improve the quality of life of the target population, through improving existing facilities and quality of services, capacity building, sharing experiences and lessons learned, and through effective networking.”

Defining key elements of scale up, India
During the “Community Lessons, Global Learning” workshop in India, participants worked in small groups to define what three of the key elements of scale-up mean in practice:
Coverage
  • Reaching a higher percentage of the population.

  • Reaching new target populations.

  • Reaching new geographical areas.

  • Increasing the range of services provided.

  • Reaching different sectors (such as government, health and the military).

Impact
  • Impact = coverage + quality.

  • Improving the quality of life of PLHA.

  • Increasing health-seeking behaviours, such as the use of STI services.

  • Reducing stigma and increasing community acceptance of PLHA.

  • Increasing access to condoms.

  • Increasing demand for services.

  • Reducing new HIV infections.

  • Involving other sectors.

Sustainability
  • Increasing community participation.

  • Maintaining a demand for services.

  • Ensuring the NGO’s financial and organisational sustainability.

  • Increasing capacity building and training, in particular among other NGOs and communities.

  • Maintaining the impact of interventions.


Similarities and differences of scale-up at community and national levels
NGOs working at community and national levels share many similar motivations for scaling up their action on HIV/AIDS. These include the fundamental desire to increase the coverage and impact of their work.

However, the focus and methods of such organisations are significantly different. For national NGOs, “going to scale” usually means achieving a critical mass of coverage of key populations at a national level. This involves assessing the “macro” gaps in the country’s response and deciding which they can fill. Meanwhile, the aspirations of community-level NGOs/CBOs focus on coverage at a local level. This is because their work is effective precisely because they operate on a small scale, working closely and intensively with people in a specific context and often modest geographic area. In practice, this may involve developing scale-up strategies that emphasise appropriate focus more than increasing coverage, while also developing the effectiveness and efficiency of their programmes.

Specific challenges of scaling-up HIV/AIDS work
Scaling up any area of development work involves challenges. However, some are either unique, or particularly acute, to HIV/AIDS. These include how to:

  • Ensure broad-based action about a sensitive issue linked to stigma and denial.

  • Achieve large-scale results for something requiring individual-level change.

  • Extend models designed for specific, marginalised communities to broader populations.

  • Cope positively with people involved in scale-up being directly affected by HIV/AIDS.

  • Monitor scaled-up impact that involves complex, personal issues such as behaviour change.

  • Sustain scaled-up action on epidemics, organisations and impacts that are subject to change.


Source: Expanding community action on HIV/AIDS
This is an extract from Expanding community action on HIV/AIDS: NGO/CBO strategies for scaling-up, published by 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 998 Kbytes).