What happens when the donors withdraw?

Community Based Organisations for HIV/AIDS and the World Bank in Zambia

Aisling Walsh1, C Mulambia2, J Hanefeld3, R Brugha1, G Walt3

1 Royal College of Surgeons in Ireland 2 Institute of Economic and Social Research, Zambia

3 London School of Hygiene and Tropical Medicine

www.ghinet.org

Research Funders

Country Studies Research

Partners

Network (GHIN) Funders

OSIOpen Soc Institute

Kyrgyzistan

Ukraine

Zambia LSHTM (UK)

EU INCODEV

Mozambique

Angola

South Africa

Burundi

Lesotho

RCSI (Ireland) Belgium

Portugal

Vietnam Sweden

Alliance for Health Policy and Systems Research

Tanzania

Uganda

Peru

China

Georgia

Malawi

Ethiopia

Benin

Malawi

Irish Aid

DANIDA

USAID SWEF

Health 20/20

RCSI

LSHTM

Background • HIV policies and structures put in place from 2000

• Importance of CBOs in Zambia for provision of advocacy and support services:

– 30% of VCT services, 80% treatment care & support, 70% OVC– 75% are local, 25% international

• World Bank MAP in Zambia $42m (2003-2008) – Zambia National Response to HIV/AIDS project (ZANARA)– Community Response to AIDS - 35% of grant

• Other funders – PEPFAR (62%) and Global Fund (16%) (2007)• Loan offer (2008) of $20m rejected by Zambian Govt

Rationale

Studies on WBMAP in Zambia have focused on:

Predicting what would occur with closure of MAP (Siamwiza, 2007) The wind down period and immediate aftermath (Hanefeld et al) An internal World Bank evaluation (2009)

Need for evidence on effects 2+ years after cessation, when deeper effects likely to have emerged.

Study aim: to produce evidence on what was the current status and activities of these CBOs in Mumbwa two years following MAP/CRAIDS cessation.

What were the range and scale of their activities at district and community level?

How had these been affected by cessation of CRAIDS funds?

Purpose: A - provide evidence to enable planning for future support to CBOs to deliver HIV

and AIDS care and support services B - provide a voice to CBOs, community/district stakeholders on activities and

needs of CBOs for HIV and AIDS.

Methods and sampling • One district – rural Mumbwa

• Consultation with NAC and DACA

• Mapping – national and district level

• 39 in-depth interviews - All CRAIDS funded CBOs (18)- District/Community AIDS Task Force members (10) - National level stakeholders (11)

• Analysis: thematic approach (ongoing)

RESULTS (1)

FUNDING

From CRAIDS to the funding gap

Pre-CRAIDS • ALL CRAIDS funded CBOs existed prior to CRAIDS • 9 CBOs had no external funding prior to CRAIDS – survived from IGAs • Funders pre-CRAIDS: PAM, HEIFER Intl, CHAZ, Millennium Change

Corporation, NGOCC, CDF - reportedly no longer funding CBOs in Zambia in 2010

CRAIDS era • Overall view of CRAIDS was very positive (all stakeholders). Initial

target of 350 projects – actual number funded was 1,800• Most heard about funding through DACA and most received funds

between 2005-2007• Size of grants ranged from K35m to K72m – some in lump sums, others

in installments• Conditions:

- More accessible than other funders- Some CBOs unhappy with conditions on services, but necessary for

even spread and availability of services throughout the district

CRAIDS cessation • CBOs: most clear about timing of grant from outset but some told that they

may get another installment. • District and national: poor communication about CRAIDS closing (district &

national)• Examples of districts where no trace of CRAIDS remains and where the

DATFs no longer exist (district and national)

Current funding opportunities • Scarce and definite decrease from 2008 • Most CBOs not aware of other sources

World Vision and Child Fund CHAZ – funded 4 CBOs in past, but currently ‘on a break’ Incorrect information on ZNAN conditions– member for 3 years with audited

accounts Little knowledge of PEPFAR or their grants MCDSS: funding scheme for OVCs

social cash transfer scheme

RESULTS (2)

CBO SERVICE PROVISION

Services provided by CBOs

• Home Based Care: nutritional support, counselling, cleaning, washing

• Transport: (mainly bicycles) to clinic/hospital, HBC• Sensitisation activities: for prevention, reduce stigma and awareness

campaigns • OVC Support: subsidies for nutrition support, school uniforms,

school fees

Effectiveness and sustainability of IGAs?

• Most CBOs engaged in IGAs such as animals, farming, cooking, knitting, hammer mills

• Enabled some CBOs to open a shop and others used farming to generate food for HBC.

Effectiveness and sustainability of IGAs? (contd)

Not always sustainable, due to lack of infrastructure – roads, bridges and small local markets

Competition amongst IGAs frequently cited Only 2 reported IGAs enabled services

levels to be maintained at CRAIDS levels

“Each time a community decided on an IGA, then it was making returns, then competition came in from new comers. The outsiders wanted to do also exactly the same thing. So they lost on the market.” (District stakeholders)

“With the hammer mill the income is very slow because we are in the midst of people who have electric hammer mills that are even more efficient… so that difference kills our business.” (CBO rep)

Current gaps in services due to CRAIDS cessation

All CBOs funded by CRAIDS are still in existence. BUT Reductions in service provision Transport the biggest obstacle Decrease in nutritional support

“For the OVCs there has been a change from when CRAIDS was funding us. There was a feeding programme. Right now we are failing to feed the children. We are also finding it very difficult to keep 100 children at school. Some of them have stopped coming to school.” (CBO rep)

Decrease in numbers supported through HBC Report of an imbalance of emphasis on treatment and prevention services

Other schemes to improve service provision - MCDSS food security programme; women and development programme; public welfare

assistance scheme (for school fees and uniforms) - MoEd: school feeding programme

RESULTS (3)

capacity building of CBOs

Capacity Building of CBOs

Volunteers are at the heart of care and support services Range in numbers from 10-100 per CBO.

Most reported a reduction in volunteer numbers

All CBOs reported capacity being built through CRAIDS - Training for psychosocial counselling, adherence support, peer

education- Business skills

Capacity continues to be built internally but

Some skills lost over time – changing technical/medical knowledge

Capacity Building (contd) Some specified the need to tailor training to suit needs of

specific CBOs

Some volunteers have been with CBO for up to 10 years

Comparative advantage- people prefer to be counselled in the community - praised for being the “only way to fight the pandemic” through community determination and hard work. - care givers have closer links as they live within the community, in essence they are the community

Some received allowances during CRAIDS

Decrease in morale – due to lack of materials, work overload

RESULTS (4)

Coordination and planning

District Coordination Structures for HIV and AIDS

DACA held in high regard by CBOs – advises, monitors, coordinates

Importance of a local leader with in-depth local knowledge.

Office of DACA located in DHO meaning now firmly situated within government health system

Uncertainty about DACA/DATF continuation (mid 2010) and lack of funding meant more difficult to carry out functions

Funding now secured through GF for next 2 years?

District Coordination Structures (contd) Recruitment of DACAs a priority for NAC in new strategic framework National level: onus should be more on DATFs as a body

CRAIDS regional coordinator: not all CBOs aware of existence and lack of understanding of their roles.

CATFs: - did not receive CRAIDS funding for services. - difficulties in covering catchment areas.

Cooperation with other providers Many positive relationships – CBOs and clinics: reciprocal

arrangements and referrals.

Cooperation with area associations outside HIV – Women’s Associations and hospital associations

Some CBOs did not work with other providers – lack of awareness of other CBOs, others for World AIDS Day only

Coordination and planning (contd)

Monitoring and Evaluation NARFs and HMIS exist in parallel but capture different indicators

Reporting a challenge – distances and lack of fuel for DACA to collect forms

Communities more motivated when monitored

Lack of awareness of NGO Act 2009 but where CBOs were aware, general positivity

Numbers of CBOs registered with DATF increased since 2008

Conclusions (1)• A.1 Conduct situation analyses of community-based AIDS

care and support services and needs in all districts

– Map AIDS care and support service provision• Organisations: CBOs, NGOs and Government services• Services: Home Based Care, food supports, support to OVCs,

Counselling, treatment adherence, Income Generating Activities

– Assess community needs for services• Target group in need of services (PLWAs, OVCs) – numbers and distribution• Numbers receiving / not receiving services – coverage levels

– Map existing funding sources – UNAIDS?– Assess CBOs’ capacities to deliver care & support services (+ do IGAs) – DATFs?– Map links between CBOs and district health facilities

Conclusions (2)

A.2 Maximise use of existing funding sources

1. Communicate existence and mechanisms for accessing funding sources

2. Funders to make funding conditions explicit to CBOs

3. Implement recommendations by• working through the DATF and CATF (note success of CRAIDS)• using media such as newspapers and local radio more effectively.

Conclusions (3)• Options for funding and supporting AIDS Care and Support

– A. Mainstream HIV care and support services within broader poverty alleviation funding channels - however, ensure that:

• The needs of PLWAs and families are prioritised

• CBOs can access funds and support to carry out their activities

• Continued support to DATFs and CATFs to carry out their coordination activities

OR / AND ?

– B. Retain a separate funding stream for community AIDS Care and Support activities

• Poverty alleviation activities can be through generic or AIDS-specific channels

• AIDS-specific / specialised support activities through these channels

QUESTIONS for DISCUSSION1. What are the community-support schemes run by the MCDSS and

the MoEd?– Are they accessible to CBOs? To PLWAs? Do they meet their AIDS care and

support needs?

2. Should community responses make special provision to target communities based on needs for AIDS care & support

3. Need for (feasibility of) conducing community situation analyses of AIDS Care and Support needs and services? Other options?

4. What should be in the AIDS community response package?– HBC, Food, Counselling, Treatment adherence, support to OVCs– IGAs (income generating activities) – need for lesson learning– Capacity-building (it is possible) + create enabling environments

QUESTIONS for DISCUSSION5. Should funding go to CBOs to do AIDS Care and Support?

– Defining what is a CBO– If so, through DATFs / district AIDS bodies or– Through Local Government bodies?

6. Sustainability – what do we mean by it?– Are there some community AIDS Care and Support activities that should be

sustained through resources from the national level (Govt and Donors)?

7. Reporting, monitoring and evaluation?– How well is the NARF (National AIDS Reporting to the NAC) working?– Are NARF data reported, analysed and acted upon?– Would there be value in evaluating the NARF M&E reporting process?

OTHER (MORE IMPORTANT)

QUESTIONS for DISCUSSION?