Mbn hiv/aids evaluation final report Team of consultants

Southern Africa (Malawi, Zimbabwe, South Africa)
India
Youth behaviour change programmes Total = 9	AFSA (seen in two projects visited*) SACBC ICOCA YONECO WASN FACT Positive Muslims Arise	Gujarat AIDS prevention
Awareness building Total = 12	AFSA (seen in three projects visited) SACBC ALP WASN SAFAIDS Positive Muslims Arise FACT Tsungirirai	Gujarat AIDS prevention SIAAP Samuha/Samraksha
VCT and counselling Total = 9	AFSA (seen in one project visited) St. Joseph care centre SACBC ICOCA Yoneco Tsungirirai Arise	SIAAP Samuha/samraksha
HBC (including counselling) Total = 11	AFSA (seen in two projects visited) St. Joseph care centre SACBC ICOCA YONECO LL diocese WASN Tsungirirai FACT	SIAAP (not HBC but a short stay centre) Samuha/Samraksha
Support to peer groups of PLWHA or affected people Total = 11	AFSA (seen in two projects visited) St. Joseph care centre SACBC LL diocese Tsungirirai FACT Yoneco Positive Muslims Plan Malawi (Napham) WASN	Gujarat AIDS prevention Samuha/Samraksha
Treatment (delivery of ARV; facilitating access to ARVs) Total = 6	St. Joseph care centre (ARV site) SACBC (ARV sites) AFSA (seen in two projects visited)	Gujarat AIDS prevention SIAAP Samuha/Samraksha
Palliative care Total = 3	St. Joseph care centre SACBC FACT
Income generating activities Total = 6	AFSA (seen in one project visited) St. Joseph care centre SACBC LL diocese Yoneco FACT
Support of OVCs (awareness building, counselling, memory boxes, school fees, food parcels, foster care) Total = 7	AFSA (seen in one project visited) St. Joseph care centre SACBC LL diocese ICOCA Tsungirirai FACT
humanitarian aid: food parcels, school fees Total = 4	AFSA (seen in two projects visited) St. Joseph care centre SACBC ICOCA

(*) Remark: AFSA and SACBC are themselves grant making organisations, facilitating grants to smaller NGOs and CBOs: AFSA funds 56 projects; SACBC 150 projects. For AFSA the team visited 3 projects. As far as SACBC is concerned, the team of ACE Europe visited St. Jospeh Care Centre (this organisation is also funded directly by Cordaid), the team of ETC visited the AIDS desk and 2 smaller projects).
Conclusions on table 20:

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  These 17 HIV/AIDS focussed organisations did develop a holistic approach, combining and linking several HIV/AIDS activities: awareness building activities, organising VCT or facilitating access to VCT sites, organising home-based care, organising peer support groups, developing activities to support orphans and vulnerable children and stimulating the setting up of income generating activities (mainly handcraft work, producing artisanal or food gardens).
  
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  Four of them also became involved in humanitarian activities like the delivery of food parcels and the payment of school fees.
  
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  Six of them are involved in treatment (delivery of ARVs or facilitating access to ARVs). The SACBC could establish 8 ARV sites in South Africa including one at St. Joseph care centre. The set up of an ARV site within a civil society organisation was long time not acknowledged by donors (such as the Global Fund) and governments and it was not easy to obtain recognition. In this perspective the ARV project was an experimental pilot project, set up by the SACBC and supported by Cordaid. The SACBC actually runs 8 ARV sites within civil society organisations, of which one has been visited in the St. Joseph Care Centre. This is the only ARV site the team visited (in addition to the ARV sites within the hospices visited –see EQ4). The other 16 organisations refer their beneficiaries to ARV sites – when existing- and five of them actively facilitate access to ARV sites by paying transport costs or paying for the medicines (ex. GAP in India), or by accompanying people to the hospices (SIAAP in India and some projects funded by AFSA).
  
• 
  Three HIV/AIDS focussed organisations were specialised in palliative care.
  

Major results achieved

All 17 HIV/AIDS focussed counterparts visited were able to achieve, within their limits, their desired outputs: constituencies have been informed, access to VCT-sites facilitated, care and support activities developed and access to treatment has been facilitated wherever possible. Many organisations refer to nearest VCT sites, hospices and work together with government services. There is a tendency to report on outputs rather than on outcomes. Impacts of the counterparts’ work in the fight against HIV/AIDS are therefore poorly supported by evidence. The evaluators could have an idea of the outcomes at the level of the beneficiaries (through the focus group discussions and internal evaluation reports). The evaluators noticed, in all counterparts visited, an increased understanding in the beneficiaries of HIV/AIDS and how to protect themselves (see judgment criteria forms in country reports which are available on request). However this understanding does not always lead to behavioural change. Beneficiaries could access information (although sometimes poor and not available in local languages), condoms (but not at all faith-based organisations) and counselling services (although not always of the same high quality). When infrastructure was available, beneficiaries were referred to VCT sites (some of the counterparts offered VCT services themselves) and/or were put on treatment (men as well as women).

In the next pages, the evaluators list some of the challenges these counterparts are facing:
Prevention: All 17 HIV/AIDS focussed organisations visited were involved in small-scale targeted prevention activities, using appropriate strategies to reach out their constituency: the instalment of youth peer education groups, the training of “role models” like traditional healers, religious leaders and school teachers, working through village committees, etc. They all went beyond information dissemination and condom distribution and are involved in life skills training and building up self esteem. Messages were usually not differentiated to men or women, unless in face to face awareness building in individual counselling (except in three organisations: WASN, Tsungirirai, GAP). Condom use was not actively promoted by the faith-based organisations (like St. Joseph Care centre, CBO’s visited that were funded by AFSA, ICOCA, Positive Muslims). One could question the effectiveness of the prevention strategies when constituencies do not have a positive vision on the promotion of safe sex and the use of condoms. It is a missed opportunity to not being able to work all together on the evidence based prevention strategy (using condoms in the fight against HIV/AIDS). The evaluators question the effectiveness of prevention strategies when constituencies do not have easy access to condoms¹⁵ (ex. St. Joseph care centre is the only primary health care service in a remote township and the only access point of many inhabitants of that region). Cordaid and ICCO are challenging this position.
HBC: Home-based care features as a programme in the majority of the sampled counterparts in Southern Africa. Considering the limitation of government outreach services, this is very relevant in the context of Southern Africa. The evaluators found that the 17 HIV/AIDS focussed organisations visited used a similar approach to home based care (training, support and follow up of home-based care givers, the organisation of home visits and the provision of food parcels). They did not observe many innovations. The quality and hence the effectiveness and efficiency of these services varied between the counterparts visited, depending on how these counterparts were dealing with the challenges they all are facing:

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  The quality of HBC services (training standards, required skills, follow up systems and rewards) differs a lot between civil society organisations and between civil society and government. This sometimes causes frictions. One could say that not all HBC services attain the same standard. In Zimbabwe, for example, governments have set minimum standards of HBC training but civil society organisations can offer less, due to financial constraints and the collapsed economy in Zimbabwe. In South Africa, follow up systems, training and required skills are not harmonised or standardised by the government, not by civil society organisations. Counterparts often lose their well-trained volunteers to government services that pay better. AFSA in South Africa (counterpart of ICCO) is advocating the government on this issue.
  
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  The majority of the 11 organisations (7) implementing HBC projects did not challenge the gender division in care, resulting in more women as care givers and few men as clients. The evaluators saw some good practices on this issue, although on small scale: Tsungirirai, LL diocese, and WASN have put efforts in recruiting more male volunteers.
  
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  Counterparts did question the increased burden put on female care givers who do not receive a decent income for their services. Most of these women are confronted with poverty and sick people within their own life and family. People and organisations try to cope with these difficult circumstances. The evaluators observed the exceptional impact of the AIDS epidemic on every aspect of life and society, especially in Zimbabwe and Malawi. Solutions are not found yet. In South Africa, the Gender AIDS Forum is advocating and lobbying on this issue¹⁶.
  
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  All HBC programmes face new challenges like the need for the development of income generating activities. Many organisations responded to the emerging needs of PLWHA who, as a result of anti-retroviral treatment are no longer bedridden or in need for HBC, needed a sustained income for themselves and their families. These initiatives lacked business plans and only provided small profits for a limited number of beneficiaries. Counterparts have been trying to find ways to respond to these expressed needs without having the necessary capacity (South Africa: AFSA, St. Joseph care centre and SACBC; Malawi: LL diocese, Yoneco, Zimbabwe: Tsungirirai).
  

OVCs: Care for OVCs is not yet a service integrated into the service packages of the Indian counterparts visited, and is not relevant yet taking into account the stage of the HIV/AIDS epidemic. According to the counterparts interviewed in Southern Africa, the problem of orphans and vulnerable children is becoming more and more omnipresent, hence many of the counterparts are responding to this need by combining counselling (including elaboration of memory boxes) and life skills development with humanitarian activities, such as paying school fees and uniforms and organising food kitchens. Seven of the 17 AIDS focussed organisations have a programme for orphans and vulnerable children (AFSA, St Joseph care centre, SACBC, LL diocese, ICOCA, Tsungirirai and FACT). Only one organisation (St. Joseph’s care centre) was also involved in the follow up foster care and Plan invests in vocational training for OVCs. Most of these counterparts cannot respond to the increasing needs, and the demands and sustainability of these activities is under pressure (not finding sustainable solutions and keeping huge donor dependency, an example being Tsungirirai which has a waiting list of OVC in need for support).
Treatment: Where government has succeeded in a free treatment roll-out programme (Malawi since 2003, South Africa since 2003, India since 2004), many counterparts refer their constituencies to these public hospitals, some of them paying transport costs or accompanying people to the hospitals (South Africa, Malawi and India). All treatment roll-out programmes are slow in implementation due to different factors (lack of commitment from government, failing public health structure, lack of human resources, etc). In South Africa the SACBC (Cordaid) has been experimenting with the set up of ARV-sites by civil society organisations with considerable success.
Support to peer groups of PLWHA or affected people: 11 counterparts have established community support groups or peer support groups for PLWHA, youth clubs, etc. As the performance and outputs of these groups has not been monitored, little information is available. The evaluators had a considerable number of focus group discussions with these kind of support groups. The sustainability of these initiatives varied, some groups could not see themselves continue if the counterpart withdrew, others did. The performance of youth clubs was challenged by the unemployment of members and the demand for incentives for their activities of community mobilisation and peer counselling. The PLWHA support groups were generally treated as beneficiaries. The evaluators saw evidence of an involvement of PLWHA – and support groups of PLWHA- in policy discussions and strategic reflections of the counterparts at three HIV/AIDS focussed organisations: FACT which established a FASO programme – Family AIDS support organisations set up and run by PLWHA, WASN that is set up and run by women living with HIV/AIDS and Samuha/Samraksha. Hence the GIPA-principle is not applied to a large extent in the majority of these AIDS organisations (only 3 of the 11 used the GIPA principle). At two organisations visited, PLWHA were incorporated in staff and assume an activist role within the organisation. SAFAIDS and WASN, both Zimbabwean organisations, positively recruit staff living with HIV/AIDS.
Gender

There is an overall weak link between gender and HIV/AIDS which can be explained by the weak gender policy- mostly limited to the collection of sex aggregated data- of most of the counterparts. Most of the counterparts do not go beyond the level of “gender sensitivity “ (see the Gupta model elaborated during the first phase of the evaluation and added to this report in annex 8). Examples could be found in the provision of the female condom, focus on income generating activities for women and increasing women’s access to health services.