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Expanding community action - 2 (strategies)
   Last updated: 29.06.02
2. Strategies for scaling-up NGO/CBO work
Based upon the practical experiences of NGOs/CBOs, particularly those participating in “Community Lessons, Global Learning” the Alliance has identified a number of strategies to scale up community action on HIV/AIDS. This chapter outlines some of those strategies, providing a brief introduction to each and one or more examples of how it has been put into practice. The final section is an analysis of some of the pros, cons and points to consider for each strategy.

In many cases NGOs/CBOs have expanded the reach of their work, without necessarily having a specific aim to “scale-up”. For example, training volunteers and peer educators to train others is an effective programme model which many NGOs/CBOs have adopted, and which has also the effect of increasing coverage. There are also examples of NGOs/CBOs that have deliberately adopted strategies with the explicit purpose of increasing the scale of their work. Such strategies include, for example, adapting models, catalysing and supporting other organisations to carry out similar work, and decentralising services.

This chapter analyses different scale-up strategies identified by Alliance partners and others, to create a “menu” of different approaches. NGOs/CBOs can implement their work to scale-up programmes by selecting appropriate strategies from this menu and developing tailor made packages which suit their specific needs and circumstances.

2.1.Expanding organisational size and/or scope
One of the most straightforward strategies for scale-up is for organisations to “mushroom” or expand laterally, increasing the amount and/or diversity of their work. In practice, this might involve NGOs/CBOs opening branches in more geographical areas, targeting different populations or providing different services. The process might take place as anything from “uncontrolled explosion” (with the work expanding spontaneously and rapidly) to “staged expansion” (with each step being carefully planned and implemented slowly).

An example of increasing organisational size was provided by Asociación de Salud Integral at the Alliance/Horizons international seminar. They scaled up their work in Guatemala City to respond to the escalating number of new infections and needs of PLHA. They focused on counselling and treatment within their hospital clinic – as no other NGOs or government groups were providing these services. Initially, they expected to see an average 15% annual increase in the number of patients. In practice, this was the case for the first two years, but in 2000 there was an increase of over 100%, due to both the expanding epidemic and greater awareness of their services.

Two further examples of this strategy were shared at the “Community Lessons, Global Learning” workshop in India. Expanding work to include new target populations was highlighted by the Sahara Center for Residential Care and Rehabilitation from New Delhi. Focusing initially on injecting drug users (IDUs), they went on to support IDUs living with HIV/AIDS, and then all local PLHA. Increasing organisational diversity was highlighted by Children of HIV Positive Individuals Living in Dignity (Project CHILD) from Mumbai. They began by providing home visits and psychosocial support to PLHA, and moved on to develop educational programmes with the children of affected families, and then advocacy work with care homes and adoption agencies.

2.2 Using cascade and multiplication models
Cascade and multiplication models involve providing intensive training to relatively small groups of individuals so that they in turn can go on to train or educate larger numbers of people. These approaches can ensure that HIV prevention messages and provision of care and support reach a larger number of people than would otherwise be possible with existing resources. NGOs/CBOs usually involve volunteers as trainers, peer educators or community outreach workers.

Working with volunteers is one of the most pragmatic strategies for scaling up local action on HIV/AIDS, particularly in resource poor settings. Volunteers come from all sections of the community and can be involved in a variety of activities, from awareness raising to working with orphans. In this way, NGOs/CBOs can considerably increase the scale of their work and can reach many more people with services that are low cost and locally owned. However, they can also face some challenges, such as the need to support a large number of people, inconsistency in the quality of work, and the rapid turnover of volunteers. On the other hand, the advantage of a high volunteer turnover, is that more and more people are trained in HIV/AIDS.

There are three main cascade and multiplication approaches, which enable NGOs/CBOs to expand their work, reaching many more people with services that are highly appropriate. Training of trainers involves supporting and training individuals in aspects of HIV/AIDS work, such as increasing knowledge or encouraging behaviour change, so that these individuals can go on to train others. Peer education is a specific approach, whereby educators share something in common with their target audience (for example, age, sexuality or occupation) increasing the appropriateness of their messages. Finally, community outreach, although less documented, is a common approached used by many NGOs/CBOs to increase the coverage and scope of their work.

An example of the versatility of peer education is provided by Programme de Développement de l’Enfant et de la Famille Ker Xalèyi (PDEF) in Senegal. This Dakar-based NGO began by supporting local mothers to act as peer educators to mobilise and educate other women about nutrition and hygiene. They then adapted this idea to their HIV prevention work supported by Alliance Nationale Contre le SIDA (ANCS), an Alliance linking organisation. This involved providing young people with intensive training (in areas such as communication skills) and moral support so that they could provide other young people with information and informal advice about issues such as sexual health, STIs and HIV/AIDS.

IPC, the Alliance linking organisation in Burkina Faso, introduced a type of community outreach work, called “Compagne de Changement de Comportement (CCC) de proximité”. This behaviour change outreach campaign allowed them to increase the impact of their existing participatory prevention work and reach more people with effective HIV prevention messages. This approach involves mobilising people who have already participated in a series of intensive discussion groups on HIV prevention to become outreach workers and facilitate discussions on HIV/AIDS in their local communities (for example in the market place or at weddings or funerals).

2.3 Adapting concepts and models
The diffusion of models is a scale-up strategy that involves NGOs/CBOs identifying effective programme approaches that have the potential to be adapted or replicated by themselves or others. Although this process has enormous potential for scale up, it also presents challenges. As the Alliance / Horizons framework paper points out:

“There is increasing frustration … with the failure of many small-scale research, pilot or demonstration projects to get “out of the hothouse” to have a larger influence on policies and programs.”

Often, individual NGOs/CBOs develop innovative and creative models and document and share their approaches, results and lessons learned extensively. In this way, the original models get scaled up – often dramatically – as other NGOs/CBOs learn about these approaches and either adapt or replicate them in their local communities.

One such example was shared by Family Health Trust (FHT) at the “Community Lessons, Global Learning” workshop in Zambia. This focused on Anti-AIDS Clubs – which bring together groups of young people aged 10-25 on a regular basis for participatory activities and discussions relating to HIV/AIDS. FHT documented the key elements of their approach – such as the subjects to cover in the Clubs and facilitation methods to use. Although FHT did plan some of their scale up in a strategic way by training volunteers to lead Clubs throughout the country, the impact was much greater than was anticipated. As a result of other NGOs/CBOs also adopting this approach, there are now a total of 2561 registered Anti-AIDS Clubs.

In other cases, NGOs/CBOs consciously set out to scale-up, by adapting their original model for other organisations to adopt. An example of this is provided by YR Gaitonde Centre for AIDS Research and Education in India [see below].

Example: Scale-up through adapting models
YR Gaitonde Centre for AIDS Research and Education, India

Starting in 1993, YRG CARE, based in Chennai, developed a client-centred, continuum of care model for PLHA. The model was monitored and improved over time. It has core elements covering not only programmatic issues (such as VCT and home based care), but also “ethical” and “human” ones. For example, as Dr Suniti Solomon says: “When I say quality, I mean that there should be a smile on the patients’ face. That is what is important.”

As their reputation grew, YRG CARE’s workload increased – with more people in their area becoming sick, and others travelling from neighbouring states to seek their services. This forced them to think strategically about how to scale up. In response, they collaborated with the Alliance to use their existing model to expand responses in under-served geographic areas, improve the quality of services, and involve a wider range of organisations. In practice, this involved building the capacity of four partner NGOs in other states in Southern India. This includes encouraging them to see and learn from the YRG CARE model in action, and providing them with intensive technical support to plan and implement a programme adapted to their own specific needs and resources.

Having started as a single bed in a mission hospital, YRG CARE is now reaching an estimated 7,674 people per year through its own care and support work and 12,173 more through its partners. Furthermore, their model is receiving increasing attention – both in other parts of India and internationally – as the potential basis for further scale-up initiatives.

2.4 Building partnerships
Strategic partnerships enable NGOs/CBOs to achieve what they cannot achieve on their own, and are an invaluable strategy for scale up. Partnership means more than casual networking, and involves building a practical relationship with other stakeholders. These stakeholders can vary from individuals (such as a mayor) to organisations (such as another NGO) or a sector (such as the religious community). Partnerships have agreed aims and objectives, focusing on mutual benefits such as technical resources or access to hard to reach communities. They can considerably contribute to scale up, particularly by pooling expertise and resources.

For example, in the Philippines, ComDev, a partner of the Philippines HIV/AIDS NGO Support Program, an Alliance linking organisation, has collaborated with the local education department in General Santos City. This partnership focuses on integrating their HIV/AIDS prevention strategies and materials into the school curriculum. It is based upon training sessions and lesson plans developed by ComDev with the teachers and school guidance counsellors, and has enabled them to increase their programme of guidance counsellors, peer counsellors and peer educators to 25 local schools. Although the NGO has continued to provide technical input, much of the support and resources now come from the local government, the city schools division and the local Rotary Club. Today the programme reaches some 58,000-65,000 secondary school students.

Views on building partnerships
“No one can ever work on HIV/AIDS alone; we have to work with other organisations. As NGOs, we can not work in isolation…we have to work with the community and we have to work with the Government.”
Dr Suniti Solomon, YRG Care, India

“It would be more useful for an NGO to network with other NGOs, rather than trying to respond to all aspects of the HIV situation alone. If an NGO works with other NGOs, or through a network of NGOs …there is a greater chance that not only will the scaled up interventions achieve more coverage, greater impact and higher quality, but also that these interventions will be more sustainable.”
Extract from report of “Community Lessons, Global Learning” workshop, India

2.5. Integrating HIV/AIDS into development work
As a development issue in itself, integrating HIV/AIDS into other development initiatives is one of the most logical scale-up strategies for NGOs/CBOs. It presents great potential for sustainable work by building on existing relationships of trust with communities. But it also involves risks – not least that agendas might clash and that one subject might dilute the other.

Many examples of integration are presented by the NGOs/CBOs supported by Alliance linking organisations. In Morocco, PASA/SIDA has encouraged integration into projects as varied as micro credit and environment. For example, L’Association des Jeunes Promoteurs et Entrepreneurs d’El Kalaa d’Esraghna (L’AJPEK) includes participatory HIV/AIDS prevention strategies in its literacy work by training young people who are already active in HIV prevention in communication techniques for adults. These trainers are then invited to introduce HIV/AIDS prevention sessions into the literacy programme. As M Saoud Mohamed concludes, “The approach has not only allowed AJPEK to reach a greater number of people…the quality of the prevention work has improved due to the relationship of trust that already existed between the trainers and the NGO, and also between the target population and the trainers”. AJPEK’s prevention messages are now reaching 600 additional community members, over half of whom are poor women.

2.6 Catalysing and supporting others
Catalysing others and providing technical support lies at the heart of the work of the Alliance and its partners. It involves mobilising other groups to start or expand their work on HIV/AIDS and providing them with the necessary support to do so effectively. This process might, for example, involve awareness raising work combined with an offer of resources, including, but not limited to, funding. It also includes the provision of technical support, which might cover any issues related to HIV/AIDS work, varying from STI treatment to external relations.

At the Community Lessons, Global Learning workshop in Zambia the Matabeleland AIDS Council presented a community level example of this strategy. In addition, Community Lessons, Global Learning workshops also highlighted a number of national examples. The HIV/AIDS STD Alliance of Bangladesh (HASAB) has mobilised over 50 local NGOs/CBOs to respond to HIV/AIDS since 1995, offering a comprehensive package of technical, organisational and financial support. In practice, this has involved a long-term partnership with the groups, including providing high quality training in programmatic areas (such as gender and sexuality) and organisational development (such as financial management), delivered through workshops and one-to-one visits.

HASAB is just one example of the linking organisations that embody the Alliance’s mission to mobilise and support community action on HIV/AIDS in developing countries. As of December 2000, the Alliance has used this strategy to work with over 1,150 local groups – increasing the number of NGOs and CBOs working on HIV/AIDS by as much as 300% in some countries.

Example: Scale-up through catalysing and supporting others
Matabeleland AIDS Council (MAC), Zimbabwe

As Marion Gotha recalls, MAC’s scale-up work was accidental: “We really didn’t want to expand and yet we had this huge catchment area – from Bulawayo to Victoria Falls – to cover. People started coming to us and saying help us. They wanted to do some HIV/AIDS work, but they didn’t know where to start, so they came to us for help. I can think of about 10 organisations that came to us in this way.”

MAC saw that, by providing technical support to these groups, they could expand both their coverage and impact. As a result, they began to support nascent organisations – helping them to develop mission statements, process legal work and set up systems. In particular, they acted as a financial match-maker – writing letters of support to vouch for the organisations to donors who were reluctant to support newly established groups.

Some of the challenges that MAC encountered included uncertainty about the quality of the CBOs’ programmes, and, as the work was not planned, some staff felt used and drained. In terms of lessons, they found that not all CBOs appreciated the amount of time and effort involved for the support organisation, but that it is still easier to work with existing groups than to start from scratch. As Marion Gotha concludes: “We came to realise that expansion for us didn’t mean being in all areas of our catchment area. It meant having partners.”

2.7. Decentralising services
De-centralising services is one of the more complex, but also more effective, strategies for NGO/CBO scale-up. It involves the transfer of decision-making and programme co-ordination from a central location to a more local level. It can take place at different levels, for example from central to provincial offices, or from an NGO to the community.

Many of the experiences of de-centralisation shared during “Community Lessons, Global Learning” referred to the national level. These included the Zambia Integrated Health Programme, which has strengthened local Neighbourhood Health Committees in 12 districts of the country. However, other NGOs, such as Chikankata Mission Hospital in Zambia [see below], shared their experience of de-centralisation at a community level.

Example: Scale-up through decentralising services
Chikankata Health Services, Zambia

The HIV/AIDS Home Based Care programme at Chikankata was set up in 1986 to meet the needs of clients and health care providers. It was based upon a model that placed their hospital at the centre of all services, reaching out to every patient.

As the epidemic and the number of patients increased, Chikankata found that support from both extended families and donors was decreasing. As a result, they saw the need to re-structure their programme, not only to increase its scale, but also to ensure its sustainability. The revised model “de-centralised” the NGO, placing the client at the centre of the model, with links to a variety of local sources of local support, of which the hospital is just one.

Before scaling up: After scaling up:

[ILLUSTRATION OMITTED]

Chikankata learned that externally led interventions can not only limit scale, but also undermine communities making them passive recipients rather than active participants. They also learned that - by decentralising their role - they can use their resources more strategically.

2.8. Influencing policy
Influencing policy – or advocacy work – involves shaping public debates by convincing people to pay attention to an issue, adopt a position and take action. Although NGOs/CBOs can be nervous about advocacy, it can be impressively successful for scale-up by converting community-based needs (such as non-stigmatisation of PLHA) into national action (such as anti-discrimination legislation). As discussed, these types of large-scale measures are crucial for the social and legal action needed for effective, far-reaching responses to HIV/AIDS. As Clement Mufuzi of the Network of Zambian People Living with HIV/AIDS says: “Advocacy is about making small noises that can lead to big changes.”

As an example, at the Alliance/Horizons international seminar, the Kenya AIDS NGO Consortium shared how it had significantly contributed to the development of the 1997 Sessional Paper No 4 “AIDS in Kenya,” as well as supporting capacity building initiatives with Members of Parliament. Meanwhile, at the “Community Lessons, Global Learning” workshop in India, Humsafar, based in Mumbai, presented their advocacy work on the rights of men who have sex with men (MSM). This involved campaigning to overturn Section 377 - legislation referring to "unnatural sexual acts" - that is punishable by up to ten years' imprisonment. While not specifically referring to homosexuality or homosexual acts, this piece of legislation is used by the police to harass the gay community. In this way, Humsafar have helped to pave the way for increased work with MSM in India by creating a more supportive environment throughout the country.

Key advantages, disadvantages and issues to consider about strategies for scale-up
Expanding organisational size and/or scope

Advantages
  • Enables an NGO/CBO to simply do more rather than dramatically change direction to scale up.

  • Builds upon an NGO’s/CBO’s existing strengths and systems.

  • Increases the presence and reputation of the NGO/CBO.


Disadvantages
  • Can lead NGOs/CBOs to simply get bigger rather than strategise about the most effective way to scale up.

  • Requires considerable scaling up of systems, staff, etc, as well as programmes.

  • Risks an NGO/CBO entering programmatic areas of which it has little experience.


Issues to consider

How can an NGO/CBO:
  • Decide whether expanding its size and / or its diversity would be best for scale-up?

  • Decide what size is appropriate and realistic to scale up to?

  • Identify what types of programmes would be most appropriate to diversify into?


Cascade and multiplication models

Advantages
  • Can be a low-cost, effective way of expanding programmes.

  • Encourages local ownership.

  • Enables more people to be trained in issues around HIV.

  • Ensures that messages are appropriate to local context.


Disadvantages
  • Can involve maintaining support to a large number or people.

  • May be difficult to maintain the quality of programmes.

  • Tends to rely on volunteers, and there may be a high turnover of people involved.


Issues to consider

How can an NGO/CBO:
  • Balance the potential increased coverage with the need to provide and maintain support for larger numbers of trainers or volunteers?

  • Identify the most suitable approach to achieve their aims and to take into account their particular circumstances?

  • Ensure that the quality of their work is maintained and that the right messages continue to be used?


Adapting concepts and models

Advantages
  • Ensures the scale-up of good practice approaches that have been tried, tested and proven to be successful.

  • Appeals to donors – as it provides them with an idea of what scale-up results to expect.

  • Provides a short-cut to scale-up work – by using existing frameworks, methods and tools.


Disadvantages
  • Risks inappropriate scale-up with general communities – by using models developed for specific, marginalised populations.

  • Can lead to the replication of approaches, rather than sensitive adaptation to specific groups.

  • Risks scale-up work being rejected - as the models used are alien and not locally owned.

  • Can require intensive mentoring by those who originally developed the models.


Issues to consider

How can an NGO/CBO:
  • Identify what models would be most useful for scaling up with the communities it works with?

  • Decide which aspects of models to replicate, and which ones to adapt to achieve successful scale-up?

  • Use external models for scale-up, but also ensure community ownership?


Building partnerships

Advantages
  • Enables NGOs/CBOs to achieve a level of scale-up that they could not achieve on their own.

  • Encourages complementarity of groups scaling up in the same area.

  • Increases the profile of the NGO/CBO.

  • Provides access to different populations, ideas and resources for scale up.


Disadvantages
  • Can require intensive effort, for example in relationship building.

  • Can be difficult to monitor and evaluate – in terms of who has achieved what.

  • Challenges the independence of individual NGOs/CBOs.

  • May tempt NGOs/CBOs into scale-up work that does not suit their strengths.


Issues to consider

How can an NGO/CBO:
  • Decide what to scale up on their own and what to do in partnership?

  • Identify the right type of partner with whom to scale up?

  • Ensure that their partnership will achieve exactly the type of scale-up that they want?


Integrating into development work

Advantages
  • Is one of the easier strategies for scale-up – by piggy-backing on existing efforts.

  • Suits scale-up in resource-poor settings with expanding epidemics – as it saves developing new programmes.

  • Facilitates scale-up by building on existing relationships of trust with communities.

  • Promotes HIV/AIDS as a non-controversial development issue, rather than one associated with stigma.


Disadvantages
  • Can cause tension between scaling up HIV/AIDS work and continuing to address other development issues.

  • Risks both subjects being diluted and poorly focused on key populations.

  • Requires people who are skilled in one area to also become skilled in another.

  • Tends to suit scaling up less in-depth HIV/AIDS work (such as community mobilisation) rather than areas such as behaviour change or care and support.


Issues to consider

How can an NGO/CBO:
  • Decide what type of development projects best facilitate the scale-up of HIV/AIDS work?

  • Maintain, in practice, a balance between a development project and HIV/AIDS work?

  • Decide whether to scale up through their own development projects or those of others?


Catalysing and supporting others

Advantages
  • Has a considerable multiplier effect – with groups mobilising others rather than implementing everything themselves.

  • Enables an NGO/CBO to scale up without having to do the groundwork (such as mobilising communities) itself.

  • May appeal to donors – as they can support many groups by working with just one.

  • Maximises existing skills – both among the support organisation and its partners.


Disadvantages
  • Requires intensive organisational and emotional inputs by the support organisation.

  • Demands diverse technical support from the support organisation – which it may not have the time or skills to provide, and which donors may be reluctant to fund.

  • Can compete with the support organisation’s ongoing work to implement programmes.

  • Raises challenges about how to ensure the quality of scale-up work, while avoiding a heavy-handed supervisory relationship.


Issues to Consider

How can an NGO/CBO:
  • Decide if it will make a good support organisation as well as a good implementing organisation?

  • Identify suitable organisations to catalyse and support to scale up?

  • Decide what proportion of their work should be support and what should be implementation, and keep a balance between them in practice?


Decentralising services

Advantages
  • Enables NGOs/CBOs to increase the scale of their work while decreasing their direct involvement.

  • Enhances the quality of scaled-up work – by ensuring that it is run locally rather than from a distance.

  • Increases the profile and reputation of the NGO/CBO scaling up.


Disadvantages
  • Can still involve the NGO/CBO in a lot of work - in terms of supporting the scaled-up services.

  • Can reduce the quality of work - due to the NGO/CBO being less hands on.

  • Risks an initiative being planted on a community rather than developed locally.

  • Can weaken the unified image of the NGO/CBO.


Issues to consider

How can an NGO/CBO:
  • Decide what type of relationship it needs to develop with its decentralised, scaled-up services?

  • Set up systems to ensure quality control of its de-centralised, scaled-up services?

  • Monitor and own the results of its decentralised and scaled-up services?


Influencing policy

Advantages
  • Enables NGOs’/CBOs’ scale-up efforts to have a large-scale, even country-wide, impact.

  • Requires few financial resources.

  • Increases the profile and reputation of the NGO/CBO scaling up.

  • Can bring indirect benefits to scale-up – such as easier access to resources.


Disadvantages
Can be a long-term scale-up process with results that are difficult to quantify.
  • Can require specific skills, for example in lobbying and writing policy briefings.

  • May involve intensive effort, for example in making contacts and building relationships.

  • Can take key staff away from implementing community projects.


Issues to consider

How can an NGO/CBO:
  • Identify which policy issues it can realistically influence?

  • Decide what policy work would bring the greatest benefits to its HIV/AIDS effort?

  • Assess whether scaling up through policy work will be worth the time and energy in terms of concrete results?


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).