AIDS orphans & Vulnerable Children An evidence-led response

1. “Keep me away from wisdom which does not cry, philosophy which does not laugh and greatness which does not bow before children” Kahlil Gibran

2. IFCW WORLD FORUM 2003 Cape Town AIDS orphans & Vulnerable ChildrenAn evidence-led response Dr Michael Elmore-Meegan FRSHTM HIV/AIDS Unit ICROSS Kenya

3. Scale and complexity of AOVC • Vulnerability • Responses • Knowing what works • Resources

4. “You do not know what is coming over the mountain, darkness is about to fall on our world – if you do not act we will be lost” Leonidas King of Sparta to the Greek states before leading 300 spartans to hold back the Persian invasion at Thermopylae 480 B.C.

5. “Know before you act everything possible from all intelligence or your plans shall fail if you are unprepared you will be defeated” Julius Caesar 51 BC

6. Scale and complexity of the problem • This is a rapidly emerging dynamic (often responded to by assumption not knowledge) • Needs to be understood in context of the broader situation. Early child development, nutrition safety, well-being, disease, emotional suffering and poverty

7. Statistics do not capture tears • The numbers miss pre-orphaned children whose their parents die difficult deaths • The data of ten misses the changes in safety, security, diet, happiness and social failure

8. Statistics and data are essential • There is limited evidence of patterns, social dynamics or psychosocial damage to children • In 3 meta-analyses , only 214 studies and 7 multi-country studies covering 4.2 million • 22 psychosocial studies underway and 7 multi-country studies being planned

9. “By 2010 an estimated 106 million children under 15 years are projected to have lost one or both parents with 25 million of this group due to HIV/AIDS” Children on the brink 2001 UNAIDS & UNICEF

10. There are other orphans, other children who are vulnerable • HIV/AIDS strikes in may ways • Some countries are more vulnerable than others • 12% of all children in sub-Sahara are orphans, 6.5% in Asia, 5% in Latin America

11. Mortality, morbidity trends reversing • Crude death rates and life expectancy changing by 2 decades in parts of Africa

12. In Sub-Sahara, by 2010 it is estimated 42million orphans, 20 million from HIV/AIDS • In 2001, 12 sub-Saharan countries made up 70% of orphan population (esp Nigeria, Ethiopia & Congo) • The mean average age on the continent of Africa is 17 (tables on www.unaids.org)

13. In AOVC • Limited hard evidence yet • Lots of material, much of poor • Lot of theories and assumptions • Short time scales • Danger of up-scaling ideas that have not been proven to work But • We know some things are working • We know what we do not know

14. We have limited resources • Where are we going to put our money? • How will we choose a project? • How will we measure success?

15. Vulnerability “History will judge us by how we cared for our children, how we protected the weak and the powerless. Civilisation is determined by our love” Albert Einstein

16. Dynamics of who is vulnerable • Starts in the household • Children’s adult-network • Children's child-network • Family network • Community network • External support structures above all internal stability

17. Our team has been looking at stress, emotional well-being, trauma and coping • Achenbach child behaviour scale • Modified triple validated scale • State of well-being scale Other important studies and assessment tools on www.repssi.org

18. Chronic vulnerability • Classically defined as exposure to risk • Exposure to stress • Lack of ability to cope with exposure symptoms e.g. Anxiety Tears Nightmares Withdrawal Terror Fear Depression Ob Compulsive D Panic

19. Important programme distinction between symptoms and causes of vulnerability Responding to SYMPTOMS relief, destitute, impoverished families livelihood failure We need to shift focus to CAUSES

20. Programmes targeting causes E.g. Family planning (demographic curves) Environment (deforestation) Climatic (floods in Asia) Policy-based Good governance Rights Land tenure

21. AOVC causes of vulnerability • Include • Household security • Rights education • Community protection of children The multiple dynamic of HIV and AIDS ripple damage to social fabric Kills most productive members of society

22. Sound cultural baselines root projects in peoples values not in donors log frames Stigma fear,denial,silence,religious objection,alienation,rejection

23. Not gender neutral Women and girls more biologically and culturally vulnerable

24. The pandemic has multiple “accelerating” effects on other risk factors (primary indices, disease patterns, economy, mortality, trends, social structures)

25. Responses As HIV impact intensifies the local, national and regional capacity to respond is decreasing

26. “A plan… we need a plan?” Homer Simson (at the controls of the nuclear plant during melt down)

27. What is working • Organised Collaborations • Networks based on equality of partners • Government linked strategies • Joint interventions are working better • Long-term integrated strategies • Multi-disciplinary responses

28. Interventions that work • Holistic approaches including MCH, PHC • Strengthening local coping systems • Community-driven safety networks • Helping formal and informal support groups

29. Protection of children’s assets • Local psychosocial safety networks • Targeting families

30. This is no longer a crisis for charities or donors alone It is a regional emergency requiring dramatic legislation, interventions and new types of alliances

31. Successful programmes have Education, social services and community support with Gov/NGO Community working together.

32. Multi-lateral institutions Bilateral institutions Government policies International organsiation programmes Community-based organisations Faith-based organisations Informal community responses

33. The problem greatly exceeds existing efforts • Little evidence of impact • Community responses often more practical in the lives of children than larger programmes

34. Less than 10% of all orphaned children are being reached by support initiatives • If AOVC are able to go to school they are performing as well as other children

35. Evidence “Walk the path that is lit, hold hands or you will walk into the ditch” Maasai proverb

36. Types of evidence • Experience • Results • Observation • Proof

37. Knowing what works (measuring and assessing program input) • Quantitative • Epidemiological • Health statistics • Demographics • Performance analysis • Cost effectiveness • Qualitative • Psychosocial • Sociological • Anthropological/cultural • Socio-economic

38. Organisations across the world are still trying programmes that never worked and were never cost-effective • Need to share • Best practices • Lessons learnt • Design skills • Evaluation methods • How to use evidence • Build through culture

39. Need to understand the difference between counting things and real information We need to plan from well-designed scientifically structured investigation and use information well But We must be cost effective and cost efficient

40. In many programmes baselines, design, methodology or knowing the real starting point are not evident • Interventions often fail to understand local context, cultural assumptions, non-negotiable values and community wisdom • Success does not depend on money but on the acceptance of the strategy by the community

41. In reviewing 28 articles on AOVC in 2002 • 19 had fundamental statistical errors • 24 had incomplete literature review • 16 had insufficient sample single • 17 had design errors • 11 had no new contribution • 8 did not understand controlling variables • 12 had no situational analysis context • 3 were recommended for publication

42. FBOs Dr Geoff Foster’s findings (686 FBOs in 6 countries – Uganda 193, Kenya 171, Mozambique 105, Namibia 91, Malawi 68 and Swaziland 57) • Material support • School assistance • HIV prevention • Visiting children/home support • Counseling and psychological support

43. Medical care • Income generation and vocational training • Day care centres • Other education • Community schools and child development centres • Promotion of foster care

44. Other responses Residential children’s homes Street children centres Community-led FBO responses were Well organised Limited impact

45. Need for partnership • Need for flexible support from donors • Need to redefine donor policies • Need to recognise role of small CBOs and FBOs and work with them www.wcrp.org www.unicef.org

46. Resources “The best things in life are free except me” Mae West There are growing resources available free on the internet with more advice, support and help. AOVC web-based resources have tripled in 2003 to 46 sites.

47. “The three richest people in the World own more than the poorest 32 countries” “The 6 richest people in the world own more than the 600,000,000 poorest” “The 250 richest people in the world own more than the 2.5 billion poorest” World Bank

48. Resources are insufficient • Global fund & multi-lateral programmes are expensive and bureaucratic • Donors are often not good listeners • Need for donors to learn from NGOs and from partner-countries, values, culture and beliefs.

49. Manuals and guides to provide psychological symptoms to children • Instruments to assess the psychological well-being of children at www.repssi.org But … these require research and interpretation skills

50. Real lessons are being learnt and shared • www.aidsalliance.org • www.ich.com • www.unicef.org • www.wcrp.org • www.aidsmap.com