Module 4

This section summarizes the publication A Question of Scale?: The Challenge of Expanding the Impact of Non-Governmental Organisations' HIV/AIDS Efforts in Developing Countries by Jocelyn DeJong (August 2001), available from the International HIV/AIDS Alliance (www.aidsalliance.org) or from the Population Council.

Overview

• What is the critical role of NGOs?
• How can existing programs be replicated and scaled-up?
• What new programs need to be delivered?

Since the beginning of the epidemic, non-governmental organizations (NGOs) and community-based organizations (CBOs) have played a leading role in designing and delivering HIV/AIDS programs. In developing an ECR response, NGOs must now grapple with complex questions about replicating and scaling-up HIV/AIDS programs; incorporating new interventions into successful programs while maintaining the programs' quality, integrating HIV/AIDS into non-HIV/AIDS programs, and networking effectively with other NGOs and government entities.

Module 4, NGO Involvement:

• Describes the types of NGOs
• Discusses how to preserve the NGO comparative advantage
• Presents strategies for NGOs to have broader impact on HIV/AIDS
• Discusses NGO/government relations
• Describes how NGO networks can support ECR
• Lists key questions for NGO involvement in ECR
• Provides a case study on NGO involvement
• Provides references and sources for further reading

Types of NGOs

A variety of NGOs are active in HIV/AIDS, from small, local organizations to large ones operating at the national level. The following are different categories of NGOs:

• Indigenous, community-based NGOs begun and managed by members of the community. Also called community-based organizations or CBOs.
• Organizations of persons living with HIV/AIDS (PLHAs).
• Indigenous NGOs established and managed by community "outsiders."
• International NGOs, sometimes referred to as private voluntary organizations (PVOs).

Each of these organizations has an important role to play in ECR, whether it is introducing new technical elements (such as home care), expanding to new geographic areas, or including new target populations within a given geographic area (clients of sex workers).

Preserving the Comparative NGO Advantage

NGOs working on HIV/AIDS have certain advantages over other types of organizations in the field. These features, which are not shared by all NGOs, include:

• Truly constituency-based organizations are committed to working within their communities.
• They are able to work with vulnerable groups, such as commercial sex workers (CSWs), intravenous drug users (IDUs), illegal immigrants, refugees and internally displaced persons.
• Their small size enables NGOs to be flexible, to respond to the rapidly evolving nature of the epidemic, and to change direction quickly to adapt to lessons learned.
• Because they are often less encumbered by bureaucracy than larger organizations or governmental counterparts, NGOs can integrate work across functions more easily, rather than be restricted to a single type of activity.
• Their commitment to the community means NGOs often provide the only sustained response to the epidemic and are more likely to offer care and support, as well as prevention activities.

The two great strengths of NGOs in HIV/AIDS prevention and care are 1) the relationships of trust built among constituencies, and 2) the processes of participatory decision making. These strengths enable NGOs to address sensitive issues in the community. The relationships that NGOs have developed over time are critical to a successful ECR implementation. The challenge is to expand programming – both geographically and in terms of content – without sacrificing these key relationships.

Successful NGO large-scale HIV/AIDS interventions have taught us that some loss of distinctiveness and integrity of process must occur to expand. However, both the AIDS Support Organization in Uganda (TASO) and the Project Support Group in Zimbabwe illustrate that it is possible to develop standardized and effective programs with enough flexibility to allow for diversity among different communities. The main question that must be addressed by NGOs and those planning and working with NGOs is whether they can maintain community-level effectiveness as they expand their coverage or services.

Strategies for NGOs to Broaden Their Impact on HIV/AIDS

An NGO can achieve wider impacts in many ways including expanding its operations; introducing or developing technologies which spread; developing and using approaches which are then adopted by other NGOs and/or by government; influencing changes in government and donor policies and actions; and gaining and disseminating understanding about development.

– Robert Chambers, "Thinking about NGO Priorities," Institute of Development Studies, May 2, 1987.

The framework of strategies (above) to broaden the impact of NGOs was developed from similar experiences in development programs. The five types of strategies presented can be viewed as a continuum along which the organization that initiates the scaling-up effort reduces its involvement over time.

It is important to note that this framework does not represent a strict evolution of organizations. NGOs may use several of these strategies simultaneously with different types of HIV/AIDS programs to respond appropriately to particular time periods, geographic areas or population groups. In addition, the staging of the continuum is not intended to imply a chronological progression, because individual organizations may decide, after assessing their own situation and environment, that any one of these broad scaling-up categories may be the most appropriate place to start.

Strategy 1: Organizational Expansion
Organizational expansion, which may be the simplest form of ECR activity, reflects the effort of one organization, rather than efforts to work with others. It increases scale by reaching a greater number of people, social groups or geographic areas, or by expanding organizational functions and activities. This may include, for example, developing a pilot project that is later expanded to a greater geographic area, or opening branches of the same organization in different places.

Strategy 2: Catalyzing Other Organizations
This strategy refers to efforts on the part of one organization to provide technical and financial assistance to other organizations within the same sector or different sectors. This is done to influence the nature or scope of the other organizations' interventions. Prevention efforts may be most effective if they are incorporated into existing infrastructures that already operate at a large scale and across a range of sectors. NGOs may seek to use and build on existing services to address HIV/AIDS. Combining HIV/AIDS interventions with delivery in other sectors, rather than focusing on scaling-up individual HIV/AIDS interventions independently, may reduce costs and improve efficiency.

Strategy 3: Diffusing Ideas
The goal of disseminating ideas is to broaden the impact by encouraging other organizations to adopt a particular concept, approach or technology. Diffusion is more abstract than the previous strategies described because it does not entail expanding or influencing an NGO's specific programs or activities, but rather spreading ideas or methodologies. One example of this strategy is an NGO spreading the concept of peer education or community counseling to other organizations.

Strategy 4: Influencing Policy and Legislation
NGOs may seek to influence the policies of influential donor organizations, government policies or legislation. This strategy can have a great impact on HIV/AIDS programming efforts. NGOs can organize efforts to shape the public debate on a particular issue – for example, reaching out to print and electronic media to increase understanding of the social determinants of HIV/AIDS. Organizations also may seek to influence policy and legislation by coalition building and knowledge exchange, striving to increase the collective demands of civil society on the government regarding HIV/AIDS.

Strategy 5: Mainstreaming in Development
Mainstreaming involves an effort to permeate all development sectors with concern for and attention to HIV/AIDS and its implications. The objective is to widen the narrow sectoral approach to HIV/AIDS by engaging decision-making bodies and organizations across relevant sectors and expanding areas for implementation beyond the traditional health sector. A greater development focus on HIV/AIDS also may encourage greater public understanding of the social contexts that put individuals at risk, such as poverty and lack of education. Awareness of less tangible and more hidden problems, such as inequitable gender relations (including women's economic dependence on men), poor self-esteem, or lack of control over how and when sex (and conception) takes place, also can be raised.

Improving Government-NGO Relations in ECR

Successful cooperation between government and NGOs in HIV/AIDS programming depends on complex factors, including the political context; mutual trust; the degree to which governments are open to NGO input; and the benefits that NGOs perceive in interacting more closely with the government. One particular challenge to address is the tendency of governments and NGOs to regard each other with suspicion, which hinders opportunities for collaboration. As HIV/AIDS prevalence rises rapidly, making the need for ECR more urgent, the need for collaboration increases. High HIV prevalence, however, is not a necessary condition for successful partnerships.

Barriers to good working relationships need to be addressed. The inability of governments to be flexible or innovative in response to changing community needs can be frustrating for NGOs. NGOs may feel they have less power than the government (depending on the political context), perceiving themselves as the "junior partner" while the government calls the shots. Similarly, government staff may be wary of working with NGOs, which they may regard as opportunistic, donor-driven, or representing the interests of particular population groups rather than the wider national audience. Competition over resources, particularly donor funding, can further inhibit collaboration between NGOs and government.

There are advantages for both governments and NGOs to fostering partnerships to increase the scale of HIV/AIDS programming:

• While government services have greater coverage at relatively low cost, they may lack an understanding of community dynamics and process approaches and, as a result, be overly intrusive or directive. Based on their knowledge and experience, NGOs can encourage more participatory methods of HIV/AIDS programming and influencing program content.

• Governments and NGOs can complement each other in terms of access to different population groups. On the one hand, governments may have sole or better access to groups, such as the uniformed services or youth in school, and can reach them on a larger scale than NGOs. On the other hand, governments may have less access to population groups engaged in illegal or stigmatized activities. One comparative advantage of NGOs is their ability to work with populations that governments often cannot reach.

• NGOs are often able to broach sensitive societal issues, increasing the legitimacy of these social problems and opening the door for later government involvement. NGO activity in some areas of HIV/AIDS, however, may deter governments from addressing these issues.

It should be noted that successful government and NGO relations are far from a one-way process – they require cooperation from both parties. Meeting these challenges to greater cooperation between government and NGOs in HIV/AIDS is critical and can produce high returns. For example, successful collaboration between government and NGOs can help change government policy on public HIV/AIDS programs, which, in turn, will affect the environments in which NGOs operate.

Supporting ECR with NGO Networks

NGOs can play an important role in ECR with their expertise in implementing intervention packages for community-based HIV/AIDS efforts and orphans and vulnerable children (OVC). But NGOs are limited because most of their programs are small and administered at relatively high cost. Capacity can be increased to expand intervention packages by establishing and strengthening NGO networks and sub-granting organizations at the country level. Specific areas where capacity can be developed or enhanced among grantee organizations include receiving and transferring resources to a large network of NGOs throughout a country; technical assistance for managing and delivering interventions; and monitoring and evaluation.

Depending on the status of NGO networks or sub-granting organizations in a given country, the latter group can assume leadership as expertise is developed in a particular intervention package or aspect of an intervention package. For instance, one NGO may assume national leadership in expanding VCT access and may develop the capacity to receive and transfer funds to a wide range of implementing NGOs and CBOs. At the community level, NGOs can network to ensure broader geographic coverage for key services. An NGO working with sex workers, for example, may network with NGOs that provide VCT and other care and support services.

Key Implementation Questions for NGO Involvement in ECR

Role of NGOs in ECR Design and Implementation

• Does your country or area have strong NGO networks?
• Does your country or area have an NGO coordination mechanism(s)? Are they effective? How can they be strengthened?
• Have you worked with (or through) NGOs that have considered expanding?
• What lessons were learned from successes/areas for improvement in program expansion?
• Are there any broad-based NGOs that could integrate HIV/AIDS into their other development programs?

Preserving the NGO Comparative Advantage

• What are the most important features of NGO programs to preserve in ECR design and implementation?
• What ways can you identify to help to preserve these features?
• What ideas can external partners consider and rank to preserve the NGO comparative advantage?

Strategies for Broadening the Impact of NGOs

• What strategies exist for broadening the impact of NGOs in HIV prevention programs? How can they be ranked in terms of importance? Care and support programs? Treatment programs? OVC programs?
• What experience is there in implementing these strategies? Which strategies have succeeded? Which ones need improvement?

Optimizing NGO-Government Partnerships to Support ECR

• How would you characterize NGO-government relations in your area? Is there an enabling environment for strong NGO-government partnerships?
• What mechanisms exist to promote NGO-government partnership and coordination?
• How have NGO-government partnerships improved and/or deteriorated over the past two to five years? What lessons can be learned from these experiences?
• What strategies can you recommended to optimize NGO/government partnerships to support ECR? Rank these recommendations by their likelihood of success.

Key Questions for Implementation of NGO Involvement in ECR

The box above lists key questions to consider when devising ways to involve NGOs in ECR. These questions are relevant for both planners and NGOs.

Further Reading

1. DeJong J. Forthcoming. A Question of Scale?: The Challenge of Expanding the Impact of Non-Governmental Organizations HIV/AIDS Efforts in Developing Countries. Horizons/Alliance, Aug. 2001.
2. Horizons 2000. NGO Scaling Up Case-Studies. Draft prepared for the Horizons and the International HIV/AIDS Alliance Seminar on Scaling Up. Windsor, England, September 1—5, 2000.
3. International HIV/AIDS Alliance. June 20001. Expanding Community Action on HIV/AIDS, NGO/CBO Strategies for Scaling Up.

Case Study – The Salvation Army's "Concept Transfer Approach" to Scaling-up

The Salvation Army is an international faith-based organization involved in HIV/AIDS care and support. To facilitate this work, the Salvation Army developed the process of concept transfer for expanding its programs and services. It is rooted in an integrated, home-based care and community prevention approach that began in 1987 at Chikankata Hospital in Zambia. From 1990 to January 2000, the concept transfer approach has been used worldwide by the Salvation Army to develop 88 programs in 37 countries, reaching an estimated four million people.

In this approach, international and regional facilitation teams work with local stakeholders to explore key issues such as participatory caring, community as belonging, change, leadership and hope. The teams engage in three learning pathways: 1) program-to-program visits; 2) attachment (or lending) of team members to organizations; and 3) courses focusing on health-related community development. Goals of the concept transfer program include:

• Increased community capacity to cope with and take responsibility for HIV/AIDS and its impact.
• Capacity development through sharing of lessons learned, transferring ideas and establishing links with other organizations.
• A developed pool of skilled people in field programs who can facilitate program development in other locations.

Major activities of concept transfer include:

• Assessment and relationship building.
• Participatory program design and support.
• Participatory evaluation, documentation and coordination of program-to-program visits.
• Regional and sub-regional consultations.
• Inter-organizational sharing for increasing capacity development and influencing policy development/formation.
• Application of lessons learned from HIV/AIDS to other areas of health and development work, analysis of the processes that facilitate change and sharing of lessons learned.

Organizational Implications for the Salvation Army
Using facilitation teams in the concept transfer approach required the organization to redefine core functions to be an effective resource in countries where it works. It also highlighted the need to continuously look outwardly and develop new perspectives that put local community capacity at the center of the work.

Staff and volunteers have become energized by the evolution of new approaches; however, the experience can be confusing and at times threatening because they do lose some control of the program. As roles are redefined, the commitment to expansion continues to be strong because of the clear benefits to this approach. This commitment sustains the new partners' involvement, which sustains expansion activities.

Lessons Learned
Program experience demonstrates that local participatory design and evaluation can succeed if assisted by a multicultural facilitation team. But challenges remain. Barriers to success include resistance to the concept transfer approach among leaders and some institutional-based programs. The effectiveness of a facilitation team depends on a highly developed sense of shared consciousness and vision, shared responsibility and team leadership. Other key lessons learned include the following:

• Successful community-to-community transfer is an incentive to other local communities.
• Leadership must be identified among team members from the resource pool during the early stage of an activity to obtain a commitment to intensive activity.
• A shared vision of local community capacity development helps the scaling-up process to develop complementary ways of working together that best serve local responses.
• Including local implementers in planning cycles – as well as representatives of the populations being served – is critically important.
• Discussing leadership and personal security issues strengthens facilitation teams and helps them bond with local stakeholders.
• Frequent policy discussions, based on concept and process analysis, are vital and most effective if they include field implementers and members of the community.