Community Based Systems in HIV Treatment (CoBaSys) .... Based Systems on HIV Treatment (CoBaSys): Strengthening Community Health Systems for HIV.
Strengthening Community Health Systems for HIV Treatment, Support and Care Ngweze area - Caprivi Region: Namibia UNAM Logo
Kenneth Matengu, Pempelani Mufune, Katri Kontio, Fortunate Machingura University of Namibia Training and Research Support Centre (TARSC) in the Community Based Systems in HIV Treatment (CoBaSys) programme ACP-EU co-operation programme in the field of science and technology
July 2011 With support from the European Commission
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Table of contents 1. 2. 3.
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5. 6. 7. 8.
Executive Summary................................................................................................................ 3 Background............................................................................................................................. 5 2.1. General Causes of High HIV Prevalence in Namibia .................................................. 7 2.2. Putting CoBaSys in Context ........................................................................................ 9 Methodology ......................................................................................................................... 12 3.1. Research setting........................................................................................................ 13 3.2. The Caprivi region: .................................................................................................... 14 3.3. Social Norms and Gender relations in Caprivi .......................................................... 16 3.4. Summary of formative research report ...................................................................... 17 Findings of the PRA research in Ngweze area .................................................................... 18 4.1. Field problems at Ngweze: ........................................................................................ 18 4.2. Mapping social and economic differentials................................................................ 18 4.3. Priority social and economic determinants that facilitate and/or enhance health service coverage.................................................................................................................... 20 4.4. Underlying intermediate and immediate causes of health needs.............................. 20 4.5. Defining HIV/AIDS responses for key social groups in health services coverage .... 22 4.6. System and mechanisms of referral care and clinical mentoring .............................. 25 4.7. Patient flow at District level........................................................................................ 26 4.8. Mapping community resources, institutions and actors that respond to HIV/AIDS ... 26 Discussion ............................................................................................................................ 26 Conclusions .......................................................................................................................... 28 Recommendations................................................................................................................ 29 References ........................................................................................................................... 31
Cite this publication as: Matengu K, Mufune P, Machingura F, Kontio k (2011) Community Based Systems on HIV Treatment (CoBaSys): Strengthening Community Health Systems for HIV Treatment, Support and Care Ngweze Area, Caprivi Region – Namibia: University of Namibia, Windhoek Acknowledgements: With thanks to the research team. Acknowledgement and gratitude to the Ngweze Research participants without them this work would not have been possible. Support to development of the protocol and report writing from Ms F. Machingura; Dr R Loewenson and B Kaim. Contact us: www.unam.ac, www.cobasys.eu , www.tarsc.org Cover picture: University of Namibia; COBASYS
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1. Executive Summary As in other southern African countries, Human Immunodeficiency Virus (HIV) and the Acquired Immunodeficiency Syndrome (AIDS) are taking their toll in Namibia. At a national level, the Ministry of Health and Social Services (MOHSS 2005) sentinel survey showed that about 19.7% of the population is infected with the virus that causes AIDS. HIV prevalence in the country was determined to be 17.8% by the 2008 Sentinel Survey. According to the 2008 Sentinel Survey (MOHSS, 2008) the highest age-specific prevalence rate in Namibia is among those aged 30-34 year. According to the recent UNDP 2009 report, Namibia, together with Botswana, South Africa and Swaziland have achieved more than 80% of the target on Preventing MotherTo-Child Transmission of HIV (PMTCT+). According to the UN, significant proportions of Namibians, particularly rural women and isolated groups, do not have complete and accurate information about HIV/AIDS prevention or treatment strategies. Many Namibians do not want to get tested for HIV due to stigma and discrimination. The rollout of ARV treatment and PMTCT+ can mitigate the stigma, but access is still limited and understanding of treatment is low. Additionally, where the ARV treatment and PMTCT+ were decentralized, seasonal factors such as floods also negatively affect the efficiency of follow-up, adherence, care and treatment regimes. Furthermore, Namibia also provides social protection and benefits for the elderly, and those with disability (World Bank (2010). Namibia has a relatively stable economy, with minerals dominating the economy. In spite of all advances in the country, more than one in four Namibian families lives in poverty. Namibia has one of the highest degrees of income inequality in the world with a gini-coefficient of 0.7071. As a key step in scaling-up a more effective, relevant and sustained primary health care and community-based HIV/AIDS treatment, care and prevention response in high prevalence resource-poor settings, ten institutions in six different countries in Africa (Zimbabwe, Namibia, Botswana, Tanzania, Malawi, and Mozambique) together with partners in Italy, England and Finland, decided to undertake a research to understand and compare community-based HIV/AIDS approaches with the ultimate aim to define best community-based HIV/AIDS service delivery practices in Africa. One of the study’s rationales is to understand community-based treatment and care efforts from the point of view of the beneficiaries. The study used mainly qualitative Participatory Reflection and Action (PRA) approaches. PRA is often associated with weaknesses of time-consumption and it is not recommended to use the approach without a follow-up commitment to take action on the problems identified. However, PRA research provides a powerful means of improving and enhancing practice by involving community dialogue at the very early stages of programme planning. Thus, it builds a basis for negotiation and partnership between researchers, resource holders and beneficiaries. Social groups in the Ngweze area of the Caprivi region identified included OVC2, People living with Disabilities, men, women, young people, the elderly and PLWHA amongst other. HIV related services that exist include VCT, awareness, ART and Home Based 1Human
Development Report - 2009. http://hdrstats.undp.org/en/countries/data_sheets/cty_ds_NAM.html 2 Orphans and Vulnerable Children
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Care. Service providers include the MoHSS3, Ministry of Gender, Red Cross, Communities and the Catholic AIDS Action. People in Ngweze are poverty stricken with main sources of income including civil service, informal business, sex work and subsistence farming The priority health problems were HIV/AIDS and Sanitation for women and men respectively. Sanitation was reported to be key social determinate of ill health and undermines treatment as PLWH continue to suffer from preventable water borne disease. Underlying intermediate and immediate causes of these health problems were linked to poor planning, poor governance and performance management within the health system. While other factors were related to: lack of information at community level and poor health worker community interactions. To enhance effective coverage of HIV services participants centred solutions on the government’s need to create an enabling environment for PLWH through intensification of already existing measures i.e. building sanitation facilities, increasing awareness campaigns, HBC, HIV information sessions. While resources and services are generally available for HIV, participants highlighted challenges of drug stock outs, and unreliable transport systems and barriers to accessibility coverage. Poor health worker0community communication was cited as a major contact coverage barrier Mapping the stakeholders in the communities revealed that while there were many service providers including FBOs4 and NGOs5 none of them provided adequate care work such as in orphan grants, food provision for OVC and PLWHIV. Social services delivery is hampered by structural limitations of the public health and welfare systems, which has contributed to the growing pressure on NGOs, CBOs, FBOs, and private sector to respond to various aspects of the epidemic. Lack of finance for nongovernmental actors and lack of efficient coordination between service providers in Caprivi has left a service gaps in the region. Related to this was the geographical location of Caprivi region as a border area- most children have foreign parents, which means that they are not entitled to the Child Welfare Grant in Namibia, despite of their legal (sometimes, illegal) residency in the country they have rights to identity. The research concludes that there are services and resources available and in place however too little to meet the demand. The poor economic status of the people Caprivi region continue to predispose them to HIV and inability to access and utilize HIV treatment, support, preventive and case services. However, there is huge potential to increase ART coverage and improve adherence rates due to decentralized service provision which has shortened distance to HIV-medical services. Recommendations pointed at the need to provide more HIV services including doctors capable of communicating in local language in the Caprivi region. Participants highlighted that coordinated responses should be part of the MoHSS planning to pool resources and coerce efforts for improved HIV service outcomes.
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Ministry of Health and Social Services Faith Based Organizations Non Governmental Organizations
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2. Background As in other southern African countries, Human Immunodeficiency Virus (HIV) and the Acquired Immunodeficiency Syndrome (AIDS) are taking their toll in Namibia. At a national level, the Ministry of Health and Social Services (MOHSS 2005) sentinel survey showed that about 19.7% of the population is infected with the virus that causes AIDS. HIV prevalence in the country was determined to be 17.8% by the 2008 Sentinel Survey. According to the 2008 Sentinel Survey (MOHSS, 2008) the highest age-specific prevalence rate in Namibia is among those aged 30-34 years.
Figure 1: National HIV Sentinel Survey Report of 2008 (Source: MoHSS 2008, Fig 9, p21) As the figure above shows, there are major differences between the regions in the northcentral and the northeastern and those in the south and western parts of the country. While the prevalence in adult age groups appears to be increasing, the prevalence in the younger age groups, (15-19, 20–24 years) is decreasing from 11 to 5.1% and 22 to 13.9% respectively between 2002 and 2008.There is no difference in HIV prevalence between urban (17.8%) and rural (17.8%) areas.
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This is down from 22% in the sentinel survey estimate for 2002. According to the same report, the seroprevalence remains highest in Caprivi although it has dropped from 43% to 31.7% in recent years. From this data, Figure 2: Trends of HIV prevalence in Caprivi region compared to it appears that Namibia 1992 - 2008 the epidemic has reached its peak and the number of first-time incidences is reducing.
Figure 3: Estimated HIV prevalence and uncertainty bounds among adults 15 years and over Source: MoHSS 2008, p14) Estimates and Projections of the Impact of HIV/AIDS in Namibia)
According to MoHSS (2008) about 204,000 people (adults and children) were living with HIV in 2007/08 in Namibia.The MoHSS estimates that 50–70% of hospital beds are occupied by people with AIDS-related illnesses, while close to 14% of children less than 15 years are orphans.Overall, although the rate of new HIV infections may be slowing down, there are now more people falling ill, dying and leaving behind a rising number of orphans and vulnerable children (OVC) countrywide.
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2.1. General Causes of High HIV Prevalence in Namibia The immediate causes of Namibia’s high HIV prevalence are high rates of unprotected sex with an infected person and mother-to-child transmission of HIV. According to the recent UN report, Namibia, together with Botswana, South Africa and Swaziland have achieved more than 80% of the target on preventing mother-to-child transmission of HIV. Nevertheless, chief among the drivers of the Namibia HIV epidemic include: multiple and concurrent partnerships, transactional and trans-generational sex, alcohol abuse, low levels of risk perception, low rates of male circumcision, inconsistent and incorrect use of condoms, and low levels of HIV testing. Structural drivers of the epidemic include elements of gender norms and inequality, mobility and migration, income disparities and poverty, educational levels and stigma as factors contributing to new HIV infections6. Additionally, among the root causes of Namibia’s high HIV prevalence include the low social economic status of women. A study by the University of Namibia (2009) also shows that women confuse menopause symptoms with those of HIV/AIDS, leading to change in sexual behaviour. Furthermore, other causes include the high level of unemployment and connected high mobility – especially of males in search of employment – contributing to the break-up of families and to the accelerated spread of HIV. Youth unemployment is as high as 75% according to the 2008 Labour Force survey. This is related to a sense of hopelessness, alcohol abuse and risky sexual behaviour. In this context, the Namibian government has been prompted to take HIV/AIDS very seriously and its response has been to mount an aggressive campaign against the epidemic. This has included surveillance, prevention, treatment, care and support, and impact mitigation. At national level, the National AIDS Coordination Programme was established in 2004. It is operated and managed by MoHSS – specifically its Directorate of Special Programmes (TB, Malaria and HIV/AIDS). Accordingly, the Directorate is the body responsible for providing assistance to all sectors in the development and implementation of sector-related HIV/AIDS activity plans in accordance with sectoral obligations as contained in the Third Medium Term Plan on HIV/AIDS (MTP3 of 20042009). This is also the body that coordinates activities of Non-Governmental Organizations (NGOs) and other donor-funded entities. According to the UN, significant proportions of Namibians, particularly rural women and isolated groups, do not have complete and accurate information about HIV/AIDS prevention or treatment strategies. Many Namibians do not want to get tested for HIV due to stigma and discrimination. The roll-out of ARV treatment and PMTCT+ can mitigate the stigma, but access is still limited and understanding of treatment, low. Additionally, where the ARV treatment and PMTCT+ were decentralized, seasonal factors such as floods also negatively affect the efficiency of follow-up, care and treatment regimes. According to MoHSS (2008) programmatic data (including estimates for private sector ART provision) approximately 50,600 individuals (both adult and children) were receiving ART as of the end of March, 2008. The Namibia Spectrum model estimated that 63,600 adults and 5,900 children were in need of ART as of 31 March, 2008 giving a total of 69,500 people in need of treatment (MoHSS, 2008 p 18). This meant that about 19,000
de la Torre et al (2008) HIV/AIDs in Namibia: Behavioral and Contextual Factors Driving the Epidemic MoHSS 6
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people in need of ART were not receiving it. The number of people expected to need ART was estimated to rise to 94,300 by the end of March, 2013 (MoHSS, 2008 p 18).
Initial Sites MHSS Additional Sites CHS and LMS
Figure 4: Distribution of PMTCT and ART sites in Namibia (Source: Fred van der Veen, Family Health International-Namibia)
According to the MoHSS (2010) country report to UNGASS there continues to be a rapid scale-up of ART services in Namibia. Thus, by 31 March 2009, 64,637 people (84% in need) were receiving treatment. This meant that 57,015 adults (83% of in need) and 7,622 children (95% of in need) in the public sector were receiving treatment. Therefore children amounted to 11% of the total patients on treatment in the public sector. Namibia considers this progress as remarkable given that the initial target for people receiving ARVs by 2009 was 25,000 before being adjusted to 70% and 90% of in need by 2009/10 for Adults and Children respectively. The country has met and exceeded both targets. People infected by HIV are also treated by the private sector and the MOHSS is in the process of ascertaining how many people are receiving ART through the private sector. Currently, it is estimated that there are 14 private hospitals in the country. Although Namibia has exceeded its targets in expanding HIV treatment access, there are challenges that if not addressed have the potential to slow the rate of expanding access to HIV treatment in the future. These include (van der Veen): • • • •
Magnitude of the epidemic is large and demand for services is high Ensuring quality care while scaling-up Shortage of skilled human resources Poverty and lack of adequate nutrition 8
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Vast, sparsely populated country
This is where the Community based systems in HIV treatment (CoBaSys) programme comes in. It is a research programme designed to help empowerlocal communities to support antiretroviral delivery programmes for patients with HIV infection in east and southern Africa (ESA). It is a regional network for policy advocacy targeting vulnerable groups in ESA and Europe with support from the European commission through the African Caribbean and Pacific (ACP) group of States. As a programme it emphasizes building solid ‘community based systems that help ensure HIV treatment to the most vulnerable social groups at primary care level.The learning and evidence from this tier of the health system is collated, synthesized fornational level advocacy and further integrated at regional level for global engagement. Thus in this context, “Treatment of HIV/AIDS encompasses a range of curative services, including treatment of opportunistic infections, tuberculosis, sexually transmitted infections and the provision of antiretroviral drugs. Beyond this clinical component, treatment is also understood to include a range of management and support interventions such as treatment literacy, psychosocial support, nutrition education and integrated management of HIV/AIDS and STIs. These measures, aimed at maximizing treatment adherence and efficacy, are essential complements to medical interventions. Treatment may involve the actions of a single provider, but often involves the actions of different providers acting simultaneously.” (Machingura et al 2010) 2.2. Putting CoBaSys in Context Namibia has a population of around 2 million, which makes it the second least densely populated country in the Southern-African region. The majority of the Namibians are poor subsistence farmers living in the northern region of the country on communal land. Northern parts of the country are prone to natural disasters such as recurrent droughts, swamps of locusts, floods and animal diseases (Ida-ElineEngh et al (2000) .Namibia is classified according to the World Bank as a lower-middle income country with a “strong multiparty parliamentary democracy that delivers sound economic management, good governance, basic civic freedoms, and respect for human rights” )World Bank (2010). Recently, Namibia was classified by IMF as an upper-middle income country. The government has improved access to primary health care; it has created a new policy to provide community-based health care (2007) and policy on HIV/AIDS (2007) and launched a policy (2004) to protect the country’s orphaned and vulnerable children. Furthermore, Namibia also provides social protection and benefits for the elderly, and those with disability (World Bank (2010). Namibia has a relatively stable economy, with minerals dominating the economy. Mining, accounts for around 25 % of gross domestic product. On the other hand, the global economic crisis has also impacted Namibia through lower demand for its commodity exports, mainly diamonds. The situation is further worsened due to declining revenues from Namibia’s membership in the Southern African Customs Union in 2010 (World Bank (2010). Labour constraints are a key problem affecting rural homesteads, in terms of formal sector and informal sector employment and cash remittances, in terms of labour for agricultural production, and in terms of homestead labour (FAO 2003) In spite of all advances in the country, more than one in four Namibian families lives in poverty. Namibia has one of the highest degrees of income inequality in the world with a 9
gini-coefficient of 0.7077. This means that the poorest 10 percent of households command just one percent of the country’s total income whereas the wealthiest 10 percent control more than half8. Furthermore, 35% of the Namibian population is surviving on $1 per day and 56% on $2 per day9. Namibia ranks 70th out of 135 developing countries in terms of human poverty index of UNDP (the Human Poverty Index, HPI-1). The HPI-1 measures severe deprivation in health by the proportion of people who are not expected to survive to age 40. Namibia also ranks 128th out of 182 countries according to the United Nation’s Human Development Index (UNDP (2009). The primary health care programs in high HIV/AIDS prevalence countries have gradually shifted from a basic primary health care orientation to concentration on HIV/AIDS services. Most of HIV related services in the rural areas focus on improving child health and maternal health through antenatal care, which offers integrated family planning and prevention of mother to child transmission of HIV services (PMTCT). Health centers and clinics have aimed also to identify HIV/AIDS patients by providing voluntary testing and counseling (VCT), refer positive patients for antiretroviral treatments (ART) and treating opportunistic infections (OI). Moreover, in terms of policy, antiretroviral medication is a part of a comprehensive community based care that supports families and communities that are affected by HIV/AIDS. Community health workers and counselors in villages serve as referral points to the health clinics and monitor treatments as part of specialized community based health services and also educate communities of prevention and treatment of health issues and take care of terminally ill patients. As a key step in scaling-up a more effective, relevant and sustained primary health care and community-based HIV/AIDS treatment, care and prevention response in high prevalence resource-poor settings, ten institutions in six different countries in Africa (Zimbabwe, Namibia, Botswana, Tanzania, Malawi, and Mozambique) together with partners in Italy, England and Finland, decided to undertake a research to understand and compare community-based HIV/AIDS approaches with the ultimate aim to define best community-based HIV/AIDS service delivery practices in Africa. One of the study’s rationales is to understand community-based treatment and care efforts from the point of view of the beneficiaries. The research approach includes communities in the process of identifying problems and finding possible solutions to accessing existing HIV/AIDS services as well as other problems related to the epidemic. This requires participatory community meetings where all right-holders and other stakeholders are present since problems and opportunities differ markedly from place to place, and suggested strategies to tackle the root causes are meaningful only when they are developed at local level. The regional synthesis of the country case-studies aim to define the community-based treatment systems, best practices and challenges and how government can involve communities more effectively in care and treatment of HIV/AIDS.The results from the CoBaSys study is meant to contribute to the design of a more comprehensive, effective and relevant community level response to enhance access and utilization of the services and ultimately reduce negative impacts of HIV/AIDS on individuals, households, 7Human
Development Report - 2009. http://hdrstats.undp.org/en/countries/data_sheets/cty_ds_NAM.html 8According to the recent Namibia Household Income and Expenditure Survey 9Population and housing census – National report: Basic analysis with highlights. Windhoek: CBS, National Planning Commission
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homesteads, and communities in Africa in general, and in Namibia in particular. Prior to the PRA study, discussions and interviews held with stakeholders for the formative research indicated that many people are not able to access health care due to out-of-pocket expenses such as travel and accommodation fees resulting in the fact that many often do not receive professional care and sometimes they drop-out. Therefore strategies were needed to make health care available and accessible to rural and remote areas. To extend the health care coverage the Primary Health Care (PHC) approach was adopted by the Ministry of Health and Social Services (MoHSS). The approach has been used to guide the restructuring of the health sector in Namibia since 1990 and it comprises of preventive, promotional, curative and rehabilitative services delivered in collaboration with other sectors, communities and partners in health (Republic of Namibia, MoHSS (2007). Over the past decade particular gains have been made in Namibia with regard to HIV care and treatment and, rolling out a more coherent and effective community-based response, albeit its inherent limitations. As the epidemic has developed, and as the demographic impacts of the epidemic on the population have become better understood, more comprehensive and sustained community-based activities have been strengthened. The Community-Based Health Care Policy, developed in 2007, provides a framework for the systematic development and maintenance of community based health care in resource-limited settings, also including services for people with HIV/AIDS and other chronic illnesses and disabilities (Republic of Namibia, MoHSS (2007). The Participatory Reflection and Action (PRA) research in the Caprivi Region of Namibia investigated barriers and facilitators to access, use and effective coverage of services and responses to HIV. The aim of the PRA was to identifying effective approaches to building community systems for responding to HIV /AIDS and services among vulnerable groups in resource poor settings. More specifically we: i. ii. iii. iv.
v.
Mapped the social economic differentials within the communities that affect risk and vulnerability to HIV and AIDS, and that may have an impact on uptake of available services for prevention, treatment and care of AIDS Identified the nature of the epidemic in the community in terms of risk groups and environments, the public health stage and burdens of the epidemic and discussed the nature of the responses needed for key social groups Mapped the resources, institutions and actors available at community and primary care level to respond to the epidemic Identified the priority social and economic determinants at individual, household, community and system level for key social groups that facilitate and block availability, access, acceptability, uptake, quality of care in and adherence to the resources above for prevention, treatment and care for HIV and AIDs (including community knowledge on social rights) Reviewed evidence and assessed opportunities and mechanisms to enhance facilitators and overcome barriers to availability, access, acceptability, uptake, quality of care in and adherence to services: (e.g. opinion leader and health worker attitudes and practices; communication processes and skills, mechanisms for social dialogue and communication; resource transfers, service organization and so on) and 11
vi.
Identified strategies for strengthening these opportunities and mechanisms as recommended by communities, health authorities, opinion leaders and key stakeholders. We looked at the actions that can be taken in the medium and long term for these strategies and the progress markers for these actions.
3. Methodology The study used mainly qualitative Participatory Reflection and Action (PRA) approaches. PRA is often associated with weaknesses of time-consumption and it is not recommended to use the approach without a follow-up commitment to take action on the problems identified. However, weaknesses are necessary tradeoffs of collaborative and adaptive research design. Moreover, sacrificing some level of time consumption and additional follow ups is well worth the additional face validity and practical significance that is gained through a PRA approach. PRA research provides an intensive yet very analytical methodological rigor and technical validity. These characteristics define the primary significance of any academic or similar research. PRA research provides a powerful means of improving and enhancing practice by involving community dialogue at the very early stages of programme planning. Thus, it builds a basis for negotiation and partnership between researchers, resource holders and beneficiaries. It is therefore important to note that the tools used to define the PRA research in this study have been peer reviewed and tested to assert significance of tools in a sound research manner. Other weaknesses associated with PRA noted in this research include:
The sampling technique can be biased. This is so because key informants (PRA research participants) who may provide with narrow and rigid views of the problems maybe inadvertently selected. Time consuming: Adequate time is needed to complete the planning process. Thus data collection without the development of a plan/protocol of action compromises the objective of the research, the findings and the conclusions of the research analysis. Thus to overcome this problem, the research should be conducted over a period of time while other factors are put on constant.
A PRA study protocol used in the research was developed; peer reviewed and pretested prior to implementation (Machingura F et al 2010). The protocol was co-authored by Machingura F, Loewenson R and Kaim B from TARSC and peer reviewed by PRA experts, University of Manchester, University of Eduardo Mondhlane, University of Namibia, University of Botswana, University of Modena, University of Helsinki, REACH trust Malawi and by the University of Zimbabwe. The tools were pre-tested in Goromonzi district by the researchers with a sample of 30 community members representing the target social groups. Researchers were trained over a3-day regional training workshop in April 2010 (Harare) on participatory methods for community based systems in HIV treatment –‘Strengthening capacitates for qualitative research using PRA approaches’ run by TARSC (TARSC 2010) The following table shows how the methodology was staged in the protocol for each objective of the research
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Table 1: Staging of Methodology and how each of the aims was addressed (Refer to Loewenson R et al 2006, Loewenson R et al 2007, Loewenson et al 2008, Loewenson et al 2009 and Machingura F et al 2010) to understand the meaning of method tools used) Objective Pre-stage 1
Method
Formative research Key informant interviews Literature review Newspaper clips Discussions with operating NGOs, planners and community representatives Research outline (further elaborated in the research COBASYS Research Protocol10 Map the social economic differentials within the communities that Social mapping, affect risk and vulnerability to HIV and AIDS, and that may have Map interview an impact on uptake of available services for prevention, Discussion treatment and care of AIDS Using this, identify the nature of the epidemic in the community in Stepwise diagram and Focus terms of risk groups and environments, the public health stage Group Discussion (use FGD and burdens of the epidemic and discuss the nature of the guide responses needed for key social groups. Identify for key social groups the priority social and economic Ranking and scoring determinants at individual household, community and system Problem tree level that facilitate and block availability, access, acceptability, Discussion uptake, quality of care in and adherence to the resources for prevention, treatment and care for HIV and AIDs (including community knowledge on social rights) Map the resources, institutions and actors available at community Stakeholder analysis and primary care level to respond to the epidemic. Plenary roundtable (community roundtable) Review the evidence to assess the opportunities and Leaping blocks mechanisms to enhance facilitators and overcome priority blocks Market place to access Discussion Identify strategies for strengthening these opportunities and Margolis wheel mechanisms as recommended by communities, health Spider web authorities, opinion leaders and key stakeholders, the actions that Group discussions can be taken in the medium and long term for these strategies Market place and the progress markers for these actions 3.1. Research setting The Caprivi region is one of 13 political regions in Namibia. It is a stretch of land in the North Eastern of the country. It borders Botswana in the East and South, Zimbabwe in the North East, Zambia in the North and Angola in the North West. The Caprivi Region borders with Kavango Region in Namibia in the West. The Caprivi region has the highest HIV & AIDS prevalence rate in Namibia. This prevalence rate was estimated at 43% in 2002 Sentinel Survey. This fell to 31.7% in the 2008 Sentinel Survey. Why is the HIV & AIDS prevalence rate so high in this Region? Part of the reason has to do with the fact 10
Machingura F, Loewenson R ,Woodhouse P, Kaim B, and CoBaSys PRA teams (2010
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that the region borders several countries that are heavily infected. The Trans-Caprivi highway connecting these countries has increased mobility among various nationals and thereby promoting sex work and related activities. Caprivi is also one of the poorest regions in the country. 3.2.
The Caprivi region:
The region is inhabited by about seven homogenous ethnic groups namely, the Masubia, Mafwe, Mayeyi, Matotela, Mambukushu, San and the Malozi. In addition, the area has a tropical climate with precipitation during the summer. Runoff from Zambia and Angola produce seasonal flooding of the Zambezi and Chobe river systems. The main urban center is the town of Katima Mulilo, with about 30 000 inhabitants. There is very little commercial farming; most of the area is in use as extensive communal pasture and small scale subsistence farming. Figure 5: Map of the Caprivi region The Caprivi region has one district referral hospital with 250 beds at KatimaMulilo. There are three health centres and 25 clinics in the region. According to Mwilima (2009) referrals from clinics are difficult for most of the year due to seasonal floods. Source: Wikipedia Ambulances cannot go to flooded areas for at least six months of the year. The KatimaMulilo has an ART clinic that provides for CD4 count and follow-up treatment. By 2009 there were 5,500 people on ART treatment and the clinic was not coping well due to increased demand (Mwilima, 2009, p 3). The table below details the HIV/AIDS treatment, care and support services according to the Ministry of Health and Social Services (2011) Health Facility Census (HFC) of 2009. The table shows aspects of PMTCT, ART services and HIV/AIDS care & support services. As can be seen 96 percent of facilities in the Caprivi offer HIV/AIDS care & support services (CSS).Among gaps in care and support services provision are: Few facilities have record system for individual client appointments observed in any relevant outpatient service site Few sites register HIV/AIDS related client diagnosis. Although 89% of sites report offering PMTCT services and almost all sites document HIV testing system only 16% offer prophylaxis to prevent MTCT or offer ARV therapeutic treatment for HIV infected women and family. Although 80% of the facilities prescribe ART and have national ART guideline, ART services are the least impressive. Only 7% of the facilities prescribe ART & provide medical follow services.
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Table 2: Caprivi health facility – HIV/AIDS treatment, care & support services PMTCT Total # health facilities 28 % of facilities reporting PMTCT services 89% Documented HIV testing system ARV prophylaxis to prevent MTCT
100% 16%
Counseling on maternal nutrition and infant feeding FP services or counseling All 4 items for minimum PMTCT package ARV therapeutic treatment for HIV infected women and family Percentage of facilities with provider of PMTCT trained in the 3 years preceding assessment Number of facilities offering any PMTCT services % of facilities offering minimum PMTCT package that have all items for PMTCT+ Number of facilities offering minimum PMTCT package ART Services Prescribe ART only Provide medical follow services only Prescribe ART & provide medical follow services Prescribe ART and/or provide medical follow services Are an outreach site for providers from outside facility % of facilities prescribing ART and having national ART guideline
96% 100% 16% 16% 76%
% of facilities prescribing ART and having other guideline % of facilities prescribing ART and having no stock-outs of normally stocked 1st line ARVs during 6 months preceding survey % of facilities prescribing ART and having laboratory capacity for monitoring art % of facilities prescribing ART and having all items to support ART Number of facilities prescribing ART and/or providing medical follow-up services
80% 100%
HIV/AIDS care & support services % of facilities offering HIV/AIDS care & support services (CSS) % of facilities with register with HIV/AIDS related client diagnosis observed in any eligible service % of facilities with record system for individual client appointments observed in any relevant outpatient service site Number of facilities offering HIV/AIDS CSS
25 50% 4 0 11% 7% 18% 0 80%
100% 0 5
96 0 22 27
Percentage of facilities with HIV testing system 97 Percentage of facilities with TB treatment and/or follow-up 90 Percentage of facilities with STI treatment 93 Percentage of facilities with primary preventive treatment for 62 opportunistic infections (such as CPT) Source: Ministry of Health and Social Services (2011) Health Facility Census (HFC) of 2009 Windhoek 15
3.3. Social Norms and Gender relations in Caprivi The ethnic groups found in Caprivi can also be found in the neighboring countries Angola, Zambia, Botswana and Zimbabwe and the social and gender norms are similar. According to 2001 National Population and Housing Census, Caprivi region has a total population of 79,826, comprising about four percent of Namibia's population11.The region is a malaria endemic area with the highest HIV-prevalence and maternal and infant mortality in the country12. Although modernization of the society has had impact on rural livelihoods, it has not changed the importance of traditional leadership structures and traditional social norms in governing society and social relations. Customary law still governs much of the daily lives of most rural Namibians and traditional leaders remain influential, and are central to decisions made at national, regional and community levels. However, since cultural traditions are dynamic rather than static traditional attitudes and practices have evolved also in Caprivi. In the region, rural families are organised around a homestead system, whereby multiple households exist in a single compound (or within a limited geographical area around a main compound). These households represent often generational relationships based on family ties13. The homestead system is intended to offer support to extended family members, a mechanism to protect households from social and economic challenges that could undermine livelihoods. Lineage and kinship, marriage decisions, inheritance patterns, and income diversification all used to be strategies aimed at protecting livelihoods and expanding influence. During the consultative meetings participants including the village headman (the induna) observed a loss of respect for the elderly and the customary law in their communities. Additionally, it was also stated that changes in rules around the sexual conduct of young people and women has changed drastically. For example, female (sikenge) and male (milaka) initiation traditions, seem to have largely fell out of practice and, despite its attempted reintroduction by the traditional leaders as a response to HIV/AIDS, it remains uncommon. Male circumcision (mukanda) has not been practiced among the ethnic groups of Caprivi, but with advocacy, also from the MoHSS, it is gaining acceptability. Yet practices that have helped to accelerate the epidemic, notably polygamy and extramarital affairs (Linyazi), are alleged to be common. During the PRA, it was noted by participants that ignorance and the abuse of alcohol also exacerbates the epidemic. Practices, such as the protection of vulnerable children in the household by a senior grandmother, or by another extended family member have declined as family structures have weakened. In the context of rapidly growing death rates among young working age adults, these traditional safety net structures have started to collapse. Further a regional stakeholder also explained in some cases that the national legislation has outlawed some of the traditional social protection practices – for instance an uncle cannot be a legal guardian for a female child according to the national law. Namibia operates on a three-tier legal system – Namibian law, customary law and General (Roman-Dutch) Law.
The Namibia 2001 Population and Housing Census http://www.npc.gov.na/census/index.htm DHS 2006-2007 13Although lesser extend as polygyny with many men in rural areas having multiple wives since this not commonly practiced among Caprivians. 11 12
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3.4. Summary of formative research report To ensure the effective implementation of the PRA protocol, a formative research phase was initiated. The aim was to understand the situation in the country and the region. All formative research activities were closely linked, with the literature review, and key informant interviews informing the adaptation of the protocol and the identification of possible issues deriving from the community discussions. The formative research results also helped in the selection of study sites, in the training of field facilitators to probe adequately and ultimately interpret the results from the PRA-meetings. As the formative research phase progressed, two key implementation recommendations emerged:
That, a Protocol including the PRA-instruments should be adapted to reflect realities in Caprivi. For example it would be unethical to invite medical personnel to participate in the three days long community meetings as recommended by the study protocol due to lack of sufficient human resources in the health facilities. As the result, it was decided to interview medical and health staff serving in the public clinics and hospitals separately. That, study sites should reflect diversity in geography, weather conditions, and differences in service provision and population characteristics in different parts of the region. Therefore, in order to detect possible differences in opinions and perceptions in different parts of the region, the study sites should be located in the areas: a) where a rural clinic provides decentralized ART services and b) where local clinic serves only as a referral point for centralized ART services in the regional hospital in the main city, KatimaMulilo and c) where re-current flooding affects provision and utilization of the health services by cutting off roads and displacing people living in emergency camps. This latter part was no possible to do because at the time of the research, the area was already flooded.
Caprivi comprises six constituencies: Kongola, Linyanti, Sibinda, Katima Mulilo Urban, Katima Mulilo Rural, and Kabe. Most of Caprivians are rural subsistence farmers and have limited access to basic social services such as schools, health centres and safer sources of water for human consumption in the region14. Also socioeconomic situation in the region compares poorly to other parts of the country: the very poor constitute 31% compared with 39%, 22% and 8% of poor, middle and better--off households respectively. A vulnerability assessment report from 2009 alluded to the overall lack of adequate capital as the main factor perpetuating the vicious cycle of poverty among the majority of poor households. The poor households have high dependency ratios15 and the most important sources of cash income among typical very poor households include casual labour, domestic work and sale of natural resources. This is supplemented with social pension among beneficiaries within this group. Household poverty is aggraveted by a highly variable weather conditions in the region: a considerable proportion of the region is flooded during the December-March period greatly restricting access to NorthEastern parts of Caprivi; on the other hand, the other parts of the region also experiences occasionally serious droughts. Farmers are unable to increase cultivable land due to lack of draft power, inputs, limited arable land particularly in the flood plains. 14 Office of the Prime Minister-Directorate Emergency Management: Caprivi Region Livelihood Baseline Profile. Low land maize and Livestock zone. Livelihood assessment, main report 2009. http://www.sadc.int/fanr/aims/rvaa/Documents/Namibia/2009%20Caprivi%20RegionLivelihoods%20baseline%20report.pdf 15Poor households typically include an average of nine members, middle households include six and rich households include five.
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4. Findings of the PRA research in Ngweze area 4.1. Field problems at Ngweze: There are many workshops being held in KatimaMulilo and many of the participants have attended workshops by various NGOs. When these NGOs hold workshops they give participants attendance certificates and pay them per-diem. The participants expected the same from our “workshop”. We spent the first one and a half hours (1.5 hours) explaining that ours was not a workshop but an Action Research that empowers both the communities and policy makers, the researcher and the researched, the community and the health worker, the affected and the infected. We further explained that participation was purely voluntary. We only succeeded in forming two groups (men and women) due to the absence of younger women (there was only two young women). Although two nurses attended on Friday (the first day at KatimaMulilo) there was only one nurse on the second day. This meant that we could not do the last two parts of the PRA. The Margolis wheel required the active participation of these health workers and one nurse was not enough. By the time we were supposed to do the last two parts, participants were vociferously complaining of tiredness and being kept too long for Saturday. Ngweze clinic was established in the mid-1990s to cater for the raising number of people in the informal settlement, south of KatimaMulilo, which are Butterfly, Cowboy and Dairy settlements. The majority of the populations are self-employed in businesses such as bakery, carpentry, vegetables and mechanical works. Four nurses are stationed at the Clinic. At the time of the PRA, which was on Friday and Saturday, days that are usually full, none of the nurses were able to participate in the study. However, one nurse from KatimaMulilo clinic (located in down-town) was available and participated in the study on Saturday. Overall, the catchment area for Ngweze clinic is estimated to be around 6000 people. This suburb has no sanitation facilities although water and electricity have now become available. 4.2.
Mapping social and economic differentials
Social/community mapping A social mapping Participatory Reflection and Action tool was used to map the HIV AIDS services, infrastructure and social groups in the Ngweze catchment area. This was aimed at identifying the social economic characteristics of the community that affect risks and vulnerability to HIV infection and that influence uptake of available services for prevention, treatment and care of people with AIDS. At Ngweze we divided participants into two groups: males, females. The male’s map highlighted traditional healer, shops, clinic, BP petrol station, church, water tank, water points, kinder garden, disabled centre, market and living quarters. The women’s map had the same things as the men’s map but with the addition of police station, the Red Cross and grave yards, projects, and gardens/fields. Social groups in the community Among the social groups that were identified in the Ngweze area were OVCs, People living with Disabilities, men, women, young people, the elderly and PLWHA. Participants noted that disabled that live near the clinic can reach services faster. Those that are far have to depend on the goodwill of others to push them to the clinic. All these groups depend on the Ngweze clinic for care, treatment and support. Fortunately for the people 18
around Ngweze, KatimaMulilo State Hospital is not far and people do access it through available taxis or even by walking. Among the HIV related services that exist in the community are: HIV Counseling and testing HIV awareness campaigns and condom distribution ARV provision Home based care for the infected Several of these services were linked them to social groups in the community: Table 3: HIV AIDS services provided in Ngweze Area HIV services Service provider HBC Food and clothing HIV/AIDS information Condoms Social grants
Catholic AIDS (CAA) Life Ambassadors
Group receiving service Action OVCs Community at large
Adherence training
OVCs Pensioners and Disabled Ministry of Health and OVCs Social Services (MoHSS) Men and women CAA Red Cross OVCs Community Counselors Men and women MoHSS PLWHA
Male circumcision
MoHSS
HIV/AIDS counseling Rapid testing
the
Ministry of Gender
Males
Among the sources of income in this community are 1) Working for government (e.g. police, schools), 2) Running informal businesses (e.g. selling at the market, running cash loans) and 3) Self-employment and crop farming. In the discussion, participants mentioned sex work as flourishing economic activity in the area. According to them sex workers do not follow HIV awareness campaigns despite efforts to include them in the interventions. Among the organizations that contribute to HIV awareness, treatment, care and support in the area are the Red Cross, Catholic AIDS Action, Life Ambassadors and TUSANO. Participants saw many gaps in resources and services in the community. They included lack of condoms for young people around 10 years, shortages of screening material, only the State hospital conducts laboratory tests and provide CD4 services, lack of cooperation (and even competition) between the various NGOs that work in the area of HIV/AIDS.
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4.3.
Priority social and economic determinants that facilitate and/or enhance health service coverage
Prioritizing health needs of PLWHA and those affected (ranking and scoring) In line with PRA guidelines set in the COBASYS PRA research protocol we used ranking and scoring PRA tool to identify priority health needs of vulnerable groups in the area while simultaneously identifying for key groups the priority factors that facilitate and block access, uptake and adherence to prevention, treatment and care for HIV and AIDS in the community. The table below gives a summary of the priority problems from the research for women and for men Table 4: Social group priority needs Identified problems Women HIV/AIDS Sanitation Poverty Men Sanitation HIV/AIDS Prostitution
Problem prioritization (Rankings) 1 2 3 1 2 3
Both men and women regarded HIV/AIDS and sanitation as major problems of the area. Ngweze is a township in Katima-Mulilo where HIV rates are highest in Namibia. It was no surprise that it was prioritized as a priority health problem by the participants. While women prioritized HIV/AIDS over sanitation, men did the opposite. They explained that lack of basic toilets meant that many people in the community were using backyards as toilets and they linked this to their everyday health problems noting that Sanitation is a social determinant of health and poor sanitation predisposes PLWH to become sick as they get exposed to diarrheal disease and other infections of poor hygiene. Women, on the other hand chose poverty while men chose prostitution as their third problem. Poverty and prostitution are linked in that lack of unemployment is driving a lot of women in the area to prostitution. This area is along the Trans-Caprivi highway meaning that there are a lot of truck drivers willing to buy the services of sex workers. It is also a major centre linking Angola, Botswana, Zambia and Zimbabwe. This again brings a lot of people willing to buy services of sex workers continuing to undermine efforts to transverse and revoke the epidemic. . 4.4.
Underlying intermediate and immediate causes of health needs
Using the COBASYS PRA protocol guidelines we used the problem tree PRA tool to identify, understand and analyze underlying health needs to intermediate and immediate causes.
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Table 5: identifying causes of priority health problems Underlying causes
Intermediate causes
HIV burden Corruption Poor follow-ups Lack of leadership (traditional leaders not involved in health issues) Local counselors not pressured to do more Poor sanitation burden Corruption Men’s failure to build toilets Failure of local council to build toilets
Community is not empowered Lack of cooperation between service providers Poor communication channels
Immediate causes
Town council failure to provide sanitation Failure of local counselors to attend to community’s problems Bad communication between community and local authorities
Lack of HIV knowledge, brochures Lack of HIV training Poverty/une mployment Rejection of HIV tests to minors
Priority problem HIV/AIDS
No pit Sanitation latrines Lack of proper hygiene Lack of safe (purified) water
Burden Caprivi has highest HIV prevalence rate in Namibia
Caprivi has highest HIV prevalence rate in Namibia partly because people are focused on more immediate diseases
These findings from the discussion suggested that Caprivi region may have the highest HIV prevalence rate in Namibia partly because people are focused on more immediate diseases such as diarrhea. As Webb (1997) argued, HIV preventative measures may not be adopted because the immediate necessities of everyday existence take precedence over long term concepts such as lower HIV risk-taking behaviour. Table 6: Solutions to identified social problems Problem Solution Lobby government for more information, awareness brochures HIV/AIDS Introduce more income generation projects to discourage sex work, intergenerational relationships and transactional sex Intensify HBC Families should boil their drinking water Sanitation Local council should increase number of taps Introduce toilet projects (such as digging pit latrines) Two things we noticed about the solutions that participants were suggesting for mitigating HIV/AIDS and the problem of sanitation: 21
(i) they centered on governmental action (e.g. income generation projects or projects to build toilets) and, (ii) They were about the intensification of already existing measures. Thus the community already has awareness campaigns, HBC, HIV information sessions, taps etc. participants feel that these are not in sufficient numbers. 4.5.
Defining HIV/AIDS responses for key social groups in health services coverage
Figure 6: Tanahashi model of health service coverage.
For Health services coverage we used the Tanahashi (1978) model that talks about availability coverage, accessibility coverage, acceptability coverage and contact coverage, again this was in line with the PRA research protocol for COBASYS. These together define whether or not there is effective coverage. This really is the issue of whether individuals that can potentially receive effective healthcare do actually receive it. Using the tool several key availability, accessibility, acceptability and contact coverage issues emerged. For availability coverage we interrogated the services that were available and those that were not and how this impacted on community systems for HIV AIDS responses. For accessibility coverage we assessed the factors that facilitate coverage and those that burden. For acceptability coverage we also debated on the factors that facilitate and those that hinder the available and accessible services and ultimately the changes and facilitators when a client reaches the facility for services. This enabled us to have an informed debate on effective coverage of resources and services for HIV in the Ngweze are of Caprivi region. Table 7 below gives a summary of our findings on effective coverage Availability coverage Available resources Unavailable resources 22
Treatment lessons (including adherence) Health education Condoms Counseling ARVs are distributed Wound dressing Circumcision Mosquito nets Milk (for babies with mothers that are PLWHA) Accessibility coverage Factors facilitating accessibility coverage Free services (these include – condoms/femidoms, health education, ARVs and family planning)
Food for people on ARVs Labour room PLWHA still pay service fee Ambulance
Factors inhibiting accessibility coverage
Acceptability coverage Factors facilitating acceptability coverage They find all the services that they access Acceptable.
Mosquito nets only given to pregnant mothers and not PLWHA Condoms not given to people younger than 15 years Family planning not given to people younger than 15 years Cleaners don’t allow patients to use clinic toilets
Factors blocking acceptability coverage
Some patients are afraid of the nurses There are no specialists in the clinic to perform circumcision Rapid testing of people under 15 is not allowed. This also applies to condoms and family planning
Contact coverage Factors facilitating contact Factors blocking contact coverage coverage Contraceptives Some patients are afraid of the nurses Counseling Under 15s do not make contact with condom, family planning and rapid testing and TB HIV/AIDS information screening services Rapid testing Health education Drugs (ARVs) It is important to note that given the poverty in Caprivi, one of the most important factors making services accessible is whether or not they are given for free. There were actions that were suggested to facilitate availability,. Accessibility, acceptability and contact coverage at i) community level ii) at the interface of communities and the health system and iii) within the health system as provided below: Availability Coverage: participants reported that youth, men and women all use contraceptives, counseling, HIV/AIDS information, Rapid testing (and TB screening), Health education and Drugs (ARVs) services whenever they are available. 23
Actions
To improve availability
Actions in the community
Actions community system Actions in system
interfacing & health the
health
Team work between men and women to ensure medication is taken on time Chairmen of community committees should be active Let traditional doctors, community leaders work together with health workers to enforce adherence MoHSS should provide enough money medication &materials Health workers should do regular follow-ups
Accessibility Coverage: Actions Actions in the community
To improve access Communities should use condoms intended purpose Actions interfacing community Educate community on condom usage and health system Actions in the health system Condoms too small – work on size Improve quality of condoms
and
for
Acceptability Coverage: Actions Actions in the community
To improve acceptability Communities should advocate for consistent free health services community Provision of reliable transport services
Actions interfacing and health system Actions in the health system
Improve availability of services communities
closest to
Contact coverage: In the Tahanashi model, contact coverage is achieved when people come into contact with services that are available, acceptable and accessible. Actions To improve contact Actions in the Community members should attend awareness campaigns community Communities have a role in building capacity and skills for young people to be responsible for the health and subsequently make informed decisions about their lives. Communities to demand provision of food for PLWHIV Actions Health workers should empower women by giving them interfacing feedback and allowing for discussions with them. community and Health workers should improve their interpersonal health system communication skills with clients Health workers should involve traditional leaders in their work (e.g. health campaigns) Actions in the More interaction with high ranking MoHSS officials and other health system relevant duty bearers for adequately informed decision making based on relevance and priority needs. 24
To ensure effective outcomes for contact coverage participants argued that there must be promotion of cooperation between health workers and community members. They recommended that high ranking MoHSS officials (e.g. health Minister) could address community to enhance principles of social accountability. 4.6. System and mechanisms of referral care and clinical mentoring Referrals occur when clients in need of HIV/AIDS care treatment and support services are forwarded or recommended for more specialized consultations, help or even information. People are referred for services that are not available at the local clinic. These include cancer, operations, labour, X Rays Pneumonia, asthma. These services are available at KatimaMulilo State Hospital. According to the WHO, Clinical mentorship is a system of practical training and consultation that fosters ongoing professional development to yield sustainable high-quality clinical care outcomes. Expertise in managing antiretroviral therapy and opportunistic infections is often not found on the district management team in programmes that are starting to scale up HIV treatment. A clinical mentor in the antiretroviral therapy context is a clinician with substantial expertise in antiretroviral therapy and opportunistic infections who can provide ongoing mentoring to less-experienced HIV clinical providers by responding to questions, reviewing clinical cases, providing feedback and assisting in case management. This mentoring occurs during site visits as well as via ongoing phone and e-mail consultation. Clinical mentoring is critical to building successful district networks of trained health care workers for HIV care and treatment in resource-constrained settings. (http://www.who.int/hiv/pub/meetingreports/clinicalmentoring/en/index.html) Health workers at Ngweze clinic say they receive clinical mentoring for HIV/AIDS through in-service training that is given to nursing staff, through regular workshops to which nurses are invited, through support visits that the MoHSS staff conducts in clinics. Despite this, gaps in clinical mentoring were observed in consistency and sustenance. . Clinical visits were reported to only occur once or at most twice a year, there are communication breakdowns between Primary Health care staff and nurses and because of pressure of work (due to shortages of enrolled nurses) few nurses are invited for in service training. Participants said that these gaps would be addressed if the MoHSS conducted more workshops and in service 25
training to nurses. They talked of the need to train more nurses so that when some are attending workshops or training sessions, others are attending to patients. We gathered that the clinic is the centre of the referral network at primary level. However, stigma and other cultural believe participants highlighted that people with disabilities living with HIV had no voice and they had no means to get to the clinic on their own. Groups that work in the community such as the Red Cross, Life Ambassadors, Peer educators HBCs, PLWHA, the Disabled and Tusano all refer people to the clinic. According to participants the ambulance is not always on time and this reduces effective flow of people. 4.7. Patient flow at District level At the district level, the referral line is from community actors (HBC, Volunteers, parents Cheshire home etc) to Ngweze clinic to Katima State Hospital to Rundu State Hospital to Windhoek (either Katutura or Central Hospital). In this sense, the system was the same as in other clinics. The only bottle necks they saw in this system included long waiting queues, and bad attitudes (rudeness) of nursing staff due to pressure of work. Participants indicated that some patients lose interest in the service because of its slowness. At the district centre (at KatimaMulilo State Hospital) participants talked of poor communication between patients and doctors. We observed that this primarily a language problem as doctors may not speak the local language. They saw improvements as lying in provision of doctors that understand the local language, SiLozior other local dialects. When ambulance drivers drop patients at Katima State Hospital, they do not bring them back to their villages. They have to find their way back home. 4.8.
Mapping community resources, institutions and actors that respond to HIV/AIDS Using the stakeholder mapping PRA tool as outlined in the COBASYS PRA protocol we identified the stakeholders in Ngweze their role and how the contribute to the community systems for HIV treatment. According to participants the Red Cross provides support and care, while Life Style Ambassadors (LA) provides condoms and Catholic AIDS Action (CAA) provides such necessities as blankets and soaps for the infected and affected by HIV. This does not mean that the other organization do not provide what the others provide. The participants pointed to lack of orphan grants, OVC support and PLWHA support (e.g. food provision) as what is lacking in services. Communities as stakeholders should engage in more care work.
5. Discussion Based on the literature review, formative research discussions and the data from the PRA, it appears that service delivery mechanisms for social services in Caprivi reflect a demand driven approach where local authorities or a village council together with service providers or beneficiaries themselves are actively involvement in beneficiary selection and benefit delivery for social safety nets such as home-based care and OVC support. The Ministry of Gender and Social Services are responsible of identifying eligible households for OVC, disability and elderly grants. OVC and foster grants underestimate of the number of children actually in need for external support. Clinical Identification is used for assessing eligibility for patients attending in the clinics for ART treatments or other medical interventions. Clinical identification is also applied to people made vulnerable due to special situations, including displaced people, refugees, and 26
institutionalised populations (e.g. orphanages), and those hospitalised due to AIDSrelated illnesses. As noted earlier the Ministry of Health and partners have acknowledged some of the practical challenges facing the implementation of OVC policy and the action plan in past years. Majority of challenges are related to a bureaucracy and a documentation (such as birth certificates and death certificates) that are essential for the OVC grants application. As birth certificates are often a pre-requisite for accessing various forms of support and many families might lack documentations, many OVC do not receive any support since this documentation is essential to ensure the grants are appropriately targeted to OVCs. According to UNICEF the second lowest percentage of registered births is in the Caprivi Region (55%). Reports alongside the interviews with the staff further point out that many children are not registered simply because their caregivers cannot afford to travel to registration points. Also a child’s parent might be buried along with their documents that are needed for grant applications. Moreover many villagers do not have access to mortuary services to obtain the necessary death certificate and bodies may be immediately buried before without knowing the need to document the death. Another challenge is related to Caprivi’s border location. Children may have foreign parents, which means that they are not entitled to the Child Welfare Grant in Namibia, despite of their legal (sometimes, illegal) residency in the country. There are also cases where a Namibian parent may be working in neighboring country as a migrant worker and die there. In these situations the necessary death certificate is difficult to obtain, which means that orphaned children are not entitled for grants. It was reported that the MGECW staff in the region take effort in cooperating with the Ministry of Home Affairs to facilitate families to receive required documentations and to help ease the process of proving the parentage of a child. However, participants also indicated that intraministerial cooperation is currently non-functional. One of the big challenges in terms of OVC services described by the MGECW and the MoHSS is human resources. The greatest bottleneck is in applying the foster and disability grants, due to the lack of social workers on the ground. Furthermore, foster grants processing is hampered by the legal process – a court order is required to approve a foster placement, and there is reported lack of human resources dedicated on child issues. Only once a court order is issued can the foster grant be applied. The findings from this research suggest that Caprivi region may have the highest HIV prevalence rate in Namibia partly because people are focused on more immediate diseases such as diarrhea. As Webb (1997) argued, HIV preventative measures may not be adopted because the immediate necessities of everyday existence take precedence over long term concepts such as lower HIV risk-taking behaviour. Two things we noticed about the solutions that participants were suggesting for mitigating HIV/AIDS and the problem of sanitation: (i) they centered on governmental action (e.g. income generation projects or projects to build toilets) and, (ii) They were about the intensification of already existing measures. Thus the community already has awareness campaigns, HBC, HIV information sessions, taps etc. participants feel that these are not in sufficient numbers 27
Long waiting queues and bad attitudes (rudeness) of nursing staff due to pressure of work, slow rate in service provision despite availability of services and resources contribute as some of major barriers inn community systems for HIBV treatment support and care.
6. Conclusions In terms of the implications of the above for community based social and health care service delivery, the following conclusions have been drawn: The material support seems to be inadequate given the amount of work carried out by the volunteers and the numbers of vulnerable children that needed to be reached. Lack of support for families and caregivers who are the most important providers of psycho- social and material support for children. Number of service providers giving home-based and OVC care & support do not meet service demand. Most communities are not yet receiving adequate assistance to care for and support for OVC. There are constituencies in region expected to have many OVCs where no service delivery is taking place. As a result a large proportion of OVCs are not benefiting any support services, partly for the reasons related to the lack of documentation and for lack of resources and capacity of the NGOs in question. Given the HIV/AIDS prevalence and with increasing strain on family networks, the proportion of OVC requiring foster care or placement is most likely to increase. The lack of social workers limits provision of foster grants, disability grants and safe place grants and although the problem has been acknowledged for some years by the Government only little progress has been made to increase service coverage. There is a need to strengthen long-term solutions for vulnerable families and communities affected by flooding including agricultural and income diversification strategies and provide more efficient social assistance. Most CHBC services so far have been established through unsystematic, needsbased efforts, especially in terms of social support for chronically ill and OVCs. Related to this, there are populations that have been made especially vulnerable due to the impacts of HIV&AIDS, and targeted services are required. These include, among others, child-headed households, children who are cared for by other children in households with high dependency ratios, those living rough, and HIV positive persons who have been subject to discrimination. HIV related NGO programs have not been carefully assessed and coordinated to meet needs for treatment and care and social services for those most in need. Majority of the active programs focus on health education and social support for PLWHA though supporting to establish a support groups or through community volunteers neglecting physical and material needs for sick and vulnerable. Overall coordination mechanism and program planning used by NGOs and FBOs appear not to address often real need of services among population and the programs appear not to be always evidence based. Focusing on few services without efficient coordination and planning with the Government and other service providers create service gaps, duplication of services and hamper efforts to support effective referral system and a continuation of the care and support for affected populations. For services that are needed by those unable to specify these service demands themselves, clinical identification mechanisms may be best (e.g. PLWHA, those affected by gender-based violence, severely malnourished and disable persons, 28
street children and under aged children in general, persons severely abusing alcohol among others). That said orphan-hood and HIV/AIDS is only one aspect of vulnerability. Other contributing factors are poverty, elderly caregivers with few resources, street children and a lack of adequate adult supervision of children, abusive caregivers and caregivers with substance abuse problems. Quality assurance, supervision, and M&E of social and health program remain critical gap areas. Also, it seems that the Government and service providers do not apply performance and result-based approaches in their offices, which might additionally attribute a slow implementation and create inefficiencies. Comprehensiveness of the services has not been assessed. Comprehensiveness refers to whether the services have targeted all those in need with the support they need, and the support they need most, and whether there are any additional or new support needs to be provided in future. Relevance of the services should be assessed. Relevance refers to the extent to which services delivered are appropriate in terms of the particular needs of those receiving the services. There is a good potential to reach most pregnant HIV positive women with PMTCT services due to the many pregnant women who attend ANC services and receive counseling. PMTCT service challenge is that few women return for postnatal care, poor feeding and caring practices including cultural beliefs, alongside with staff shortages and limited skilled birth attendance and limited community support. Possibility to increase ART coverage and improve adherence rates might be higher than earlier due to decentralized service provision which has shortened a distance to HIV-medical services.Where health care services are available and within reach people make use of the services for the benefit of themselves.
7. Recommendations Generally, Namibia is doing moderately well addressing the HIV related needs of OVCs and PLWHA – at least comparing to the most of other high prevalence countries in the world. For instance Namibia has comprehensive policies and programs to meet HIVrelated needs of PLWHA and OVCs. However, it seems that the delivery of communitybased social and health services have not kept pace with the severity and breadth of service needs and impacts themselves. It has become increasingly clear that the emphasis on centralized service delivery response initiatives must give way to more decentralized better coordinated service provision to help Namibia to cope with severe impacts of the pandemic in the country. In this respect, despite the gains made in the coherence of policy and programme, the quantitative goals set for the universal access for those in need, as elaborated in the policy objectives, have not been met. As in many countries, in Namibia health facility management of people living with HIV/AIDS goes on very well, while the community component is lagging. Also, evidently there are acknowledged problems with registration of OVCs and lack of service providers for home-based care. For instance the quality and coverage of OVC and care and treatment for bed-ridden being provided is a matter of concern. Social services delivery is hampered by structural limitations of the public health and welfare systems, which has contributed to the growing pressure on NGOs, CBOs, FBOs, and private sector to respond to various aspects of the epidemic. This includes the visible and growing need to support and care for PLWHA and others who are affected by 29
the epidemic, particularly OVC, as well as need of engagement of communities in prevention, and treatment related activities. Lack of finance for non-governmental actors and lack of efficient coordination between service providers in Caprivi has left a service gaps in the region. Given this context the findings and the conclusions, we therefore recommend that: Attitudes of service providers, local/traditional leaders, health workers, government officials (local counselors) and community members can all make a difference to enhance engagement and improvement in uptake of HIV treatment, care and support services. Health care providers are key to service provision but the quality of that provision may depend on their cultural competence (the extent they converse in the local language, they make efforts to respect clients etc.) There is thus a profound need to provide doctors that understand the local language, Local NGOs e.g. Life Ambassadors, CAA, Red Cross seem to be crucial to the delivery of materials to OVCs, awareness, condoms and even home based care in Caprivi but they do so in isolation and building cooperation and capacity may be crucial to service uptake. Thus coordinated responses should be part of the MoHSS planning to pool resources and coerce efforts for improved HIV service outcomes.
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8. References 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16)
17) 18) 19) 20) 21) 22) 23)
FAO (2003). HIV/AIDS and Agriculture: Case Studies from Namibia, Uganda and Zambia de la Torre et al (2008) HIV/AIDs in Namibia: Behavioral and Contextual Factors Driving the Epidemic MoHSS Ida-ElineEngh et al (2000): HIV/AIDS in Namibia: The impact on the livestock sector.Population Programme Service (SDWP), FAO Women and Population Division Accessible at http://www.fao.org/sd/wpdirect/wpan0046.htm Loewenson R., Kaim B .,Mbuyita, S. Chikomo, F., Makemba, A. Ngulube, TJ (2006) Participatory methods for people centred health systems, A Tool Kit for PRA Methods TARSC Harare Loewenson R, Kaim B, Machingura F (TARSC) Kelemi C (BONELA), Mhotsha G. (BFTU) (2009) Health Literacy guide for people centred health systems: Botswana, TARSC Harare Low, A. D. de Coeyere, N. Shivute and L. Brandt, 'Patient referral patterns in Namibia: identification of potential to improve the efficiency of the health care system’ International Journal of Health Planning and Management, 16 (2001) Machingura et al 2010Strengthening Community Health Systems for HIV Treatment, Support and Care Goromonzi District Zimbabwe Machingura F, Loewenson R ,Woodhouse P, Kaim B, and CoBaSys PRA teams (2010); Participatory Research Protocol for Community PRA meetings in community based HIV treatment in Zimbabwe, Malawi, Tanzania, Botswana, Namibia and Mozambique; Training and Research Support Centre; Zimbabwe; HarareMoHSS Report of the 2008National HIV Sentinel Survey MoHSS Windhoek MoHSSEstimates and Projections of the Impact of HIV/AIDS in Namibia 2008 MoHSS (2010) Country report to UNGASS MoHSS Windhoek Ministry of Health and Social Services (2011) Health Facility Census (HFC) of 2009 Windhoek Ministry of Labour: 2009:2008 Labour Force surveyMoL Windhoek Mwilima, 2009 Drivers of the HIV epidemic in the Caprivi region, MA thesis Namibia KIT Royal Tropical Institute Netherlands Vrije University Amsterdam Republic of Namibia, MoHSS (2007),Community-Based Health Care Policy- Draft 1/11/2007, Republic of Namibia , Windhoek Shivute et al 2008, The use of information and communications technology for health service delivery in Namibia: perspectives of the health service providers IST-Africa 2008 Conference Proceedings, Paul Cunningham and Miriam Cunningham (Eds), IIMC International Information Management Corporation, 2008, ISBN: 978-1-905824-07-6 Tanahashi T. Health service coverage and its evaluation. Bulletin of the World Health Organization, 1978;56(2):295-303. Available at: http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_295-303.pdf van der Veen, Fred: ART in Namibia Family Health International Windhoek Namibia http://www.womenchildrenhiv.org/wchiv?page=cp-wa-00-00 UNDP (2009) Human Development Report 2009 http://hdrstats.undp.org/en/indicators/105.html WHO 2005: WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings. Geneva http://www.who.int/hiv/pub/meetingreports/clinicalmentoring/en/index.html World Bank (2010), Namibia: Country Brief. Accessible at http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/AFRICAEXT/0,,contentMDK :20214657~pagePK:146736~piPK:226340~theSitePK:258644,00.html
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