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11. The Importance of Context
   Last updated: 16.08.02
 
All of the above strategies are necessarily contingent on the context in which the organisation finds itself operating – such as the policy context and where the official government position on the HIV/AIDS epidemic lies on a continuum from complete denial to mainstreaming HIV/AIDS across all areas of development. The general political context will also play a determining role, whether in terms of the extent of state capacity, its accountability to public demands or the degree of transparency with which it governs. Political considerations would reflect the degree to which NGOs are given some autonomy within which to operate and the scope available for community organising without fear of repression. Many have argued, however, that even adverse political contexts do not necessarily mitigate against scaling up efforts (Myers 1992; Sittitrai 1994; Smith and Colvin 2000). Indeed, where governments are incapacitated for various political reasons – such as in complex emergencies – NGOs may find valuable opportunities for initiating activities at a greater scale. In these contexts, however, the most likely strategy is neither strategy 4 nor 5 above, but rather careful and low-key efforts to catalyse other organisations (strategy 2) and to diffuse community-based approaches to HIV/AIDS prevention, voluntary counselling and testing as well as care and support for those affected (strategy 3).

Capacity would also include the availability of government infrastructure and the degree to which government provides a minimum safety net for its citizens. This, of course, will in turn be affected by the economic situation prevailing in the country, and the adoption of macro-economic policies such as structural adjustment, which may severely constrain budgetary resources. Where economic or logistical constraints interrupt the supply of commodities – such as treatment for opportunistic infections or condoms, for example -- this can hamper the most successful models of scaling up as both the Program Support Group in Zimbabwe and TASO in Uganda have noted (Case study presentations). If capacity is very low, it is likely that there will be a ceiling to efficiency gains through expansion and at a certain scale of delivery, further investment in capacity and infrastructure will be necessary in order to be able to expand activities and exploit potential economies of scale (Kumaranayake 2000). Where state capacity and willingness to address HIV/AIDS are both low, for example, strategies of scaling up may focus on the NGO sector alone, rather than building bridges with government services.

The epidemiological context is also a key factor – including the stage and dynamics of the epidemic. Where, for example, governments are still in denial and the epidemic is still not significantly advanced into the general population, there are not likely to be many NGOs active in HIV/AIDS either on the prevention side or in care and support. Those that do exist are likely to be impeded in their access to communities and to the mass media.26 Thus, partnerships may need to be sought with organisations active in development to a broader degree, or through other entry-points such as reproductive health or gender issues. In some contexts, however, the fact of government denial may provide a window of opportunity for NGOs; for example, in Ecuador, precisely because the government does so little in HIV/AIDS many NGOs were created to respond to some of the needs of PLHA (Margarita Quevedo, personal communication). Nevertheless, despite the importance of the level of the epidemic, NGOs do not always articulate different strategies whether their countries or areas have high or low prevalence of HIV/AIDS.27

26 This is the case in Egypt, for example, where despite significant capacity and a relatively good health infrastructure, there are few NGOs active in HIV/AIDS (professional experience of the author from working in Egypt 1992-99).

27 Indeed, discussion of how the level of epidemic affects strategy was notably missing from the Horizons/Alliance Seminar.

The feasibility of delivering scaled up interventions will also be conditioned by the intervention context and how difficult it is to reach population groups, both in terms of social and physical access. Thus, for example in contexts which have a relatively low level of urbanisation and in which populations are dispersed in remote rural areas, or among migrant communities scaling up is likely to be both resource- and time-intensive. Cultural considerations will dictate the degree of taboo surrounding the discussion of sex generally and the stigma associated with particular sexual orientations (such as homosexuality) or sexual activity (such as sex work) as well as with injecting drug use and other potentially high-risk behaviours.

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).