At the Horizons/Alliance Seminar, a set of preconditions (see Figure 8 - below) to NGOs scaling up their activities was proposed by Baba Goumbala of the ANCS in Senegal.

Figure 8 - Six Preconditions for Scaling up Source – Baba Gamboula, ANCS, Senegal (Horizons/Alliance Seminar)

• Evaluation is necessary before expansion.

• The desire and willingness to do more and better must come from inside the NGO and not be imposed from outside.

• The NGO must have the resources and capacity appropriate to the scaling up.

• The scaling up should be initiated at the NGO’s own rhythm and at the rhythm of the community.

• The NGO must control the know-how and direction of the scaling up transition process.

• The population(s) who will be reached must be the most appropriate regarding their vulnerability and their potential to act as vectors of social change.

While each of these preconditions was discussed extensively at the seminar, and is open to debate, consensus emerged that scaling up in HIV/AIDS need not always proceed at the “rhythm” of the community for many issues or groups may be disregarded or ignored if left only to the choice of communities themselves. Thus there may be an inherent conflict between the “rhythm” of the NGO and that of the community or communities concerned, and there is often a necessary role, it was argued, for outside agencies to stimulate action related to these sensitive concerns or marginalised social groups.

If NGOs do decide to initiate scaling up processes, three elements become extremely important to contemplate in ensuring that the organisation is sufficiently prepared. The first is that time and resources are devoted to planning for the scaling up process. The second is that organisations analyse their own comparative advantage within the larger picture of activities within the HIV/AIDS sector. Thirdly, the institution must consider the internal implications of scaling up for leadership, management, staffing, structure and costs. The later internal dimensions will be further addressed in the final section of this publication, whereas the focus here is on questions of strategy and effectiveness.

A number of programmatic questions must be addressed before the scaling up exercise begins. These include the question of who to focus on, both in terms of the beneficiaries of interventions, as well as whether the scaling up exercise would be confined to the original organisation (strategy one above) or work with other institutions - NGO, private or governmental (strategies 2 – 5 above). In terms of the beneficiaries, for example, should the scaling up focus on increasing the numbers of people reached in absolute terms, or concentrate on those most likely to affect the dynamics of the epidemic, or perhaps most likely to adopt behavioural changes?28

28 Questions posed by Jeff O’Malley, email of 13 June 2000

In some cases, NGOs that successfully scaled up their programmes present at the Horizons/Alliance Seminar did focus on the groups most vulnerable to HIV/AIDS. PSG for example, explicitly targets HIV/AIDS vulnerable and low-income communities. Similarly, the Healthy Highways Project in India – an initiative of the UK Department for International Development and the Government of India including a number of NGO partners such as the Naz Foundation – specifically targets truck drivers (and their partners) as being most vulnerable to HIV/AIDS because of their mobility.

Such an approach based on epidemiological notions of risk is often highly effective but may tend to narrow emphasis on the target groups without looking sufficiently at their partners or the circumstances governing their sexual behaviour. For example, Allan Ragi of KANCO notes that neglected groups have been the wives of truck-drivers or secretaries in the companies for which they work.

If one follows a social model of health, and endeavours to understand the social processes driving the epidemic, then one may emphasise groups more likely to bring social change – that is, “vectors of social change” rather than the “vectors of the epidemic” (the former term was favoured at the Horizons/Alliance Seminar). For example, SIAAP chose to work with an innovative target group of blind people. On epidemiological criteria alone, this may not seem an effective group to focus on given their relatively small population size.29 However, the fact that the blind are particularly disadvantaged in gaining access to HIV/AIDS material (most of which is written) or may be more stigmatised than most when purchasing condoms, for example, make this an important group to focus on in social terms, if one’s objective is to counter stigma associated with HIV/AIDS.

29 Their actual epidemiological risk has not been studied. C. Ramachandran of SIAAP notes that they may be at high risk because they tend to marry later, and often live in hostels or institutions for the blind (personal communication).

Moreover, if one’s objective in scaling up is to build on indigenous community initiatives, then of interest is how one can stimulate spontaneous links between and among communities. For example, the orphan support programmes that FACT/FOCUS has supported expanded through links between church groups to other communities.

The second key question is what to focus on in scaling up in terms of particular HIV/AIDS activities.30 This in turn will depend on a number of dimensions, including the feasibility of particular strategies – including technical aspects and questions of access to necessary resources (such as condoms or pharmaceuticals), costs as well as political considerations.

30 See appendix B for a list of HIV/AIDS interventions from a public health perspective and Appendix: C for a description of the evolving focus of the HIV/AIDS alliance on different types of HIV/AIDS interventions in its support of community action in the field of HIV/AIDS.

The second dimension would be the effectiveness of scaling up particular strategies, which points to the need for research to inform the strategies chosen. Yet NGOs often do not have the requisite information to assess effectiveness, either because they lack exposure to technical innovations or new findings or results of interventions tested elsewhere, or do not have the resources or orientation to undertake research themselves (Sittitrai 1994).