What happens when the donors withdraw?

1. What happens when the donors withdraw? Community Based Organisations for HIV/AIDS and the World Bank in Zambia Aisling Walsh1, C Mulambia2, J Hanefeld3, R Brugha1, G Walt3 1 Royal College of Surgeons in Ireland 2 Institute of Economic and Social Research, Zambia 3 London School of Hygiene and Tropical Medicine www.ghinet.org

2. RCSI Irish Aid DANIDA LSHTM USAID SWEF Health 20/20

3. Background HIV policies and structures put in place from 2000 Importance of CBOs in Zambia for provision of advocacy and support services: 30% of VCT services, 80% treatment care & support, 70% OVC 75% are local, 25% international World Bank MAP in Zambia $42m (2003-2008) Zambia National Response to HIV/AIDS project (ZANARA) Community Response to AIDS - 35% of grant Other funders – PEPFAR (62%) and Global Fund (16%) (2007) Loan offer (2008) of $20m rejected by Zambian Govt

4. Rationale Studies on WBMAP in Zambia have focused on: Predicting what would occur with closure of MAP (Siamwiza, 2007) The wind down period and immediate aftermath (Hanefeld et al) An internal World Bank evaluation (2009) Need for evidence on effects 2+ years after cessation, when deeper effects likely to have emerged.

5. Study aim: to produce evidence on what was the current status and activities of these CBOs in Mumbwa two years following MAP/CRAIDS cessation. What were the range and scale of their activities at district and community level? How had these been affected by cessation of CRAIDS funds? Purpose: A - provide evidence to enable planning for future support to CBOs to deliver HIV and AIDS care and support services B - provide a voice to CBOs, community/district stakeholders on activities and needs of CBOs for HIV and AIDS.

6. Methods and sampling One district – rural Mumbwa Consultation with NAC and DACA Mapping – national and district level 39 in-depth interviews - All CRAIDS funded CBOs (18) - District/Community AIDS Task Force members (10) - National level stakeholders (11) Analysis: thematic approach (ongoing)

7. RESULTS (1) FUNDING From CRAIDS to the funding gap

8. Pre-CRAIDS ALL CRAIDS funded CBOs existed prior to CRAIDS 9 CBOs had no external funding prior to CRAIDS – survived from IGAs Funders pre-CRAIDS: PAM, HEIFER Intl, CHAZ, Millennium Change Corporation, NGOCC, CDF - reportedly no longer funding CBOs in Zambia in 2010 CRAIDS era Overall view of CRAIDS was very positive (all stakeholders).Initial target of 350 projects – actual number funded was 1,800 Most heard about funding through DACA and most received funds between 2005-2007 Size of grants ranged from K35m to K72m – some in lump sums, others in installments Conditions: More accessible than other funders Some CBOs unhappy with conditions on services, but necessary for even spread and availability of services throughout the district

9. CRAIDS cessation CBOs: most clear about timing of grant from outset but some told that they may get another installment. District and national: poor communication about CRAIDS closing (district & national) Examples of districts where no trace of CRAIDS remains and where the DATFs no longer exist (district and national) Current funding opportunities Scarce and definite decrease from 2008 Most CBOs not aware of other sources World Vision and Child Fund CHAZ – funded 4 CBOs in past, but currently ‘on a break’ Incorrect information on ZNAN conditions– member for 3 years with audited accounts Little knowledge of PEPFAR or their grants MCDSS: funding scheme for OVCs social cash transfer scheme

10. RESULTS (2) CBO SERVICE PROVISION

11. Services provided by CBOs Home Based Care: nutritional support, counselling, cleaning, washing Transport: (mainly bicycles) to clinic/hospital, HBC Sensitisation activities: for prevention, reduce stigma and awareness campaigns OVC Support: subsidies for nutrition support, school uniforms, school fees Effectiveness and sustainability of IGAs? Most CBOs engaged in IGAs such as animals, farming, cooking, knitting, hammer mills Enabled some CBOs to open a shop and others used farming to generate food for HBC.

12. Effectiveness and sustainability of IGAs? (contd) Not always sustainable, due to lack of infrastructure – roads, bridges and small local markets Competition amongst IGAs frequently cited Only 2 reported IGAs enabled services levels to be maintained at CRAIDS levels “Each time a community decided on an IGA, then it was making returns, then competition came in from new comers. The outsiders wanted to do also exactly the same thing. So they lost on the market.” (District stakeholders) “With the hammer mill the income is very slow because we are in the midst of people who have electric hammer mills that are even more efficient… so that difference kills our business.” (CBO rep)

13. Current gaps in services due to CRAIDS cessation All CBOs funded by CRAIDS are still in existence. BUT Reductions in service provision Transport the biggest obstacle Decrease in nutritional support “For the OVCs there has been a change from when CRAIDS was funding us. There was a feeding programme. Right now we are failing to feed the children. We are also finding it very difficult to keep 100 children at school. Some of them have stopped coming to school.” (CBO rep) Decrease in numbers supported through HBC Report of an imbalance of emphasis on treatment and prevention services Other schemes to improve service provision MCDSS food security programme; women and development programme; public welfare assistance scheme (for school fees and uniforms) MoEd: school feeding programme

15. RESULTS (3) capacity building of CBOs

16. Capacity Building of CBOs Volunteers are at the heart of care and support services Range in numbers from 10-100 per CBO. Most reported a reduction in volunteer numbers All CBOs reported capacity being built through CRAIDS Training for psychosocial counselling, adherence support, peer education Business skills Capacity continues to be built internally but Some skills lost over time – changing technical/medical knowledge

17. Capacity Building (contd) • Some specified the need to tailor training to suit needs of specific CBOs • Some volunteers have been with CBO for up to 10 years • Comparative advantage • - people prefer to be counselled in the community • - praised for being the “only way to fight the pandemic” through community determination and hard work. • - care givers have closer links as they live within the community, in essence they are the community • Some received allowances during CRAIDS • Decrease in morale – due to lack of materials, work overload

18. RESULTS (4) Coordination and planning

19. District Coordination Structures for HIV and AIDS DACA held in high regard by CBOs – advises, monitors, coordinates Importance of a local leader with in-depth local knowledge. Office of DACA located in DHO meaning now firmly situated within government health system Uncertainty about DACA/DATF continuation (mid 2010) and lack of funding meant more difficult to carry out functions Funding now secured through GF for next 2 years?

20. District Coordination Structures (contd) • Recruitment of DACAs a priority for NAC in new strategic framework • National level: onus should be more on DATFs as a body • CRAIDS regional coordinator: not all CBOs aware of existence and lack of understanding of their roles. • CATFs: • did not receive CRAIDS funding for services. • difficulties in covering catchment areas. Cooperation with other providers • Many positive relationships – CBOs and clinics: reciprocal arrangements and referrals. • Cooperation with area associations outside HIV – Women’s Associations and hospital associations • Some CBOs did not work with other providers – lack of awareness of other CBOs, others for World AIDS Day only

21. Coordination and planning (contd) Monitoring and Evaluation NARFs and HMIS exist in parallel but capture different indicators Reporting a challenge – distances and lack of fuel for DACA to collect forms Communities more motivated when monitored Lack of awareness of NGO Act 2009 but where CBOs were aware, general positivity Numbers of CBOs registered with DATF increased since 2008

22. Conclusions (1) A.1Conduct situation analyses of community-based AIDS care and support services and needs in all districts Map AIDS care and support service provision Organisations: CBOs, NGOs and Government services Services: Home Based Care, food supports, support to OVCs, Counselling, treatment adherence, Income Generating Activities Assess community needs for services Target group in need of services (PLWAs, OVCs) – numbers and distribution Numbers receiving / not receiving services – coverage levels Map existing funding sources – UNAIDS? Assess CBOs’ capacities to deliver care & support services (+ do IGAs) – DATFs? Map links between CBOs and district health facilities

23. Conclusions (2) A.2Maximise use of existing funding sources Communicate existence and mechanisms for accessing funding sources Funders to make funding conditions explicit to CBOs Implement recommendations by working through the DATF and CATF (note success of CRAIDS) using media such as newspapers and local radio more effectively.

24. Conclusions (3) Options for funding and supporting AIDS Care and Support A. Mainstream HIV care and support services within broader poverty alleviationfunding channels - however, ensure that: The needs of PLWAs and families are prioritised CBOs can access funds and support to carry out their activities Continued support to DATFs and CATFs to carry out their coordination activities OR / AND ? B. Retain a separate funding stream for community AIDS Care and Support activities Poverty alleviation activities can be through generic or AIDS-specific channels AIDS-specific / specialised support activities through these channels

25. QUESTIONS for DISCUSSION What are the community-support schemes run by the MCDSS and the MoEd? Are they accessible to CBOs? To PLWAs? Do they meet their AIDS care and support needs? Should community responses make special provision to target communities based on needs for AIDS care & support Need for (feasibility of) conducing community situation analyses of AIDS Care and Support needs and services? Other options? What should be in the AIDS community response package? HBC, Food, Counselling, Treatment adherence, support to OVCs IGAs (income generating activities) – need for lesson learning Capacity-building (it is possible) + create enabling environments

26. QUESTIONS for DISCUSSION Should funding go to CBOs to do AIDS Care and Support? Defining what is a CBO If so, through DATFs / district AIDS bodies or Through Local Government bodies? Sustainability what do we mean by it? Are there some community AIDS Care and Support activities that should be sustained through resources from the national level (Govt and Donors)? Reporting, monitoring and evaluation? How well is the NARF (National AIDS Reporting to the NAC) working? Are NARF data reported, analysed and acted upon? Would there be value in evaluating the NARF M&E reporting process?

27. OTHER (MORE IMPORTANT) QUESTIONS for DISCUSSION?