31 Uvin and Miller (1996) refer to “push” factors for scaling up which are largely supply-driven - that is, where the impetus for scaling up comes from the programme providers themselves, usually NGOs or government; and “pull” factors where demands for scaling up emerge from the recipients or participants of the intervention programme. Nonetheless, there is a need to further disaggregate these categories. Moreover, in practice expansion is likely to result from a combination of motivations.

Expansion may be externally induced if the overall context in which NGOs operate changes, either because of the evolution of the HIV/AIDS epidemic itself (as it expands rapidly, and/or extends into other social groups or geographic areas, for example) or the natural history of the disease (with increasing proportions of the beneficiary community becoming symptomatic). The overall policy climate may change, either in a negative or positive direction due to changes in government stances regarding HIV/AIDS, or the activities of other organisations. Alternatively, the beneficiaries of an organisation may be the driving force behind expansion in that they may demand a greater scale in terms of the numbers of persons reached, geographic areas covered or the type of activities undertaken. In many cases increasing the scale of activities is part of a deliberately conceived research process, beginning with a pilot study and involving a staged programme of expansion. As noted above, the Program Support Group, for example, began as an ethnographic study in the University of Zimbabwe, and subsequently moved into service delivery. Research continues to inform their on-going programme.

In other instances, the introduction of new technologies – for example the female condom or microbicides - may drive efforts to expand the scale of activities. International pressure and advocacy or the evolution of ideas at the international level often play a key role in inspiring certain forms of expansion. As was evident at the International Conference on Population and Development for example, when a particular approach – such as integrating HIV/AIDS within reproductive health care – is endorsed at the international level, this can play a very influential role in the design of local programmes. The extent to which such integration is indeed desirable and is actually happening, however, remains debated (Mayhew 1996).

The desire for expansion may have little to do with external factors but rather be entirely internally motivated, either at the initiative of a visionary and charismatic leader or through staff consensus. Funding is then sought to finance the planned expansion. Expansion may stem from observed success in smaller-scale activities and the desire to expand this effort. Alternatively, it may be driven internally by discovery of obstacles to successful programmes. For example, the Self Employed Women’s Association, in Ahmedabad, India – a trade union with a membership of over 200,000 women - developed to represent the economic interests of disadvantaged women but expanded into health when staff found that the main reasons for defaults on loans were maternal mortality and health problems.

There may be personal motivation such as a desire for professional advancement, social recognition or prestige that provide the underlying impetus to programme expansion. In many cases, leaders of organisations stake their careers on the visibility, influence and indeed size (as measured in numbers of employees or in overall budgets) of the organisations they direct. The notion that NGOs need to increase in size in order to compete with other organisations for donor funding or influence is widely held according to participants in the Horizons/Alliance Seminar. As Jeff O’Malley notes in the case study on the HIV/AIDS Alliance: “It is rare indeed for an NGO of any size to conclude that it is doing enough, or that it has enough resources.”

The degree to which the initiating organisation perceives itself to be in control of the process of expansion in large part reflects the nature of this motivation. In a workshop convened by the UK NGO AIDS Consortium, for example, many participants spoke of the involuntary nature of scaling up, in that they felt they were obliged to take on other activities because of overwhelming poverty and the lack of services in the face of a devastatingly rapid spread of the epidemic. In these circumstances, the lack of time, opportunity or resources to prepare for scaling up can have a detrimental effect on its ultimate effectiveness. In other situations where control is equally lacking – where expansion is induced by the exigencies of foreign funding, for example, scaling up may actually dilute effectiveness.

Similarly, selecting among strategies as defined above in the typology may not be a result of free choice, and indeed organisations may resort to certain strategies rather than others as a compromise. Where funding is not available to catalyse other organisations (strategy 2), for example, some might engage in policy advocacy with both government and donors in order to encourage them to provide the necessary funds to support grassroots activities.32