Background – Zambia 14% HIV prevalence 2007, 6% of funding for HIV came from domestic sources

1. Sustainability of Community Based Organisations for HIV/AIDS care and suppport services in Zambia 2nd February 2012 Aisling Walsh1, C Mulambia2, J Hanefeld3, R Brugha1,3 www.ghinet.org 1 RCSI; 2 Institute for Economic and Social Research, University of Zambia; 3 London School of Hygiene and Tropical Medicine

2. Background – Zambia 14% HIV prevalence 2007, 6% of funding for HIV came from domestic sources CSOs in Zambia – increased tenfold since 1990s (Birdsall and Kelly, 2007) World Bank Multi-country AIDS Programme in Zambia – Community Response to AIDS (CRAIDS) $42m (2003-2008) Change of strategy through World Bank Agenda for Action, 2007-2011 Study aims Evaluate whether the WBMAP in Zambia contributed to the sustainability of Community Based Organisations (CBOs) working in HIV/AIDS in Zambia Make recommendations for promoting the sustainability of these CBOs This presentation will focus on: Funding for CBOs Role of volunteers & links between ‘formal’/’informal’ health workers Make recommendations for improved sustainability of CBOs

3. What is sustainability? First entered development discourse early 1990s (Bossert 1990, Lafond 1995) Definitions include both financial and programmatic dimensions, and has contested meanings: Donors: project costs are borne by locals without further international aid Policymakers: initiative reinvigorated to stand the test of time “A contribution to the development of conditions enabling individuals, communities and local organisations to express their potential, improve local functionality, develop mutual relationships of support and accountability, and decrease dependency on insecure resources (financial, human, technical, informational) in order for stakeholders to negotiate their respective roles in the pursuit of health and development, beyond a project intervention.” (Sarriot et al, 2004)

4. Methods and sampling One district – Mumbwa rural Mapping – national and district Sample: 34 in-depth interviews (March – May 2010) All CBOs that received/did not receive CRAIDS funding Reps from community/district coordinating bodies for HIV National level respondents (n=6) (November 2010)

5. Results (1): Funding for CBOs All 18 CBOs that received CRAIDS funding had existed prior to funding, some as early as 1992 AND all existed post CRAIDS cessation National level perception that CBOs emerged to access funds without proper plans AND that CBOs had disappeared since CRAIDS ceased 9 had no external funding prior to CRAIDS, relying on Income Generating Activities Funding opportunities in 2010 scarce.

6. Results (2): Volunteers - the pulse of the community response Numbers in individual CBOs ranged from 10 to 100 Motivation – described as coming from a desire to improve community Some volunteered with same CBO for up to 10 years. Comparative advantage – PLWHA prefer to be counselled by care givers from within their own community No allowances/incentives allowed, though some allowances through IGAs. Services provided by volunteers Home-based care: nutritional support, counselling, cleaning and washing. Transport: (mainly bicycles) for promoting ART adherence, travel to clinics OVC support: subsidies for nutrition support, school uniforms

8. Results (3): Links between formal and informal health workers Positive relationships between community based counsellors and ART programmes Some volunteers had been given positions on hospital committees, and reported “ working in the clinic as a team alongside medical staff.” Results (4): Decreases in services since CRAIDS ceased All CBOs still functioning, all reported decreases in service provision Biggest obstacle – lack of transport Decrease in morale reported and some care givers had discontinued HBC visits.

9. Discussion: Keeping the volunteer pulse beating Little evidence to show that volunteerism can be sustained for long periods (WHO, 2007) Govt and donors rarely support payments to community level health workers in Zambia – changing with CHW Strategy (2010)? Commitment amongst existing volunteers was high and most volunteers worked for no allowances. Decreases in numbers of volunteers was reported amongst CBOs

10. Conclusions WB espoused the idea of sustainability, but more on the periphery than at the heart of their strategy Sustainability achieved through CRAIDS engagement with existing CBOs All CBOs in place pre-CRAIDS and all continued to exist Placed the community at the centre – funding a bottom-up community-articulated needs approach HOWEVER No capacity to maintain/scale-up level of service provision Sustainability for CBOs at local level dependent on national level

11. Way forward and recommendations Assessment of need is essential (though ‘soft services’ prove more difficult to cost and evaluate) 2. Numbers of volunteers and their role needs to be monitored more closely. 3. Integrate HIV/AIDS into other development initiatives, eg Mother and Child Health 4. Work with existing structures and mechanisms 5. Funding: mainstream HIV/AIDS care and support services within broader poverty alleviation funding channels. Would need to ensure that PLWHA would received specialist support services from within the broader channel

12. “So we are very successful because we have not believed in living on sponsorship. We have believed that we must be self sustainable in our own small way because that’s the only way we can fully exist. Because if we normally depend on sponsorship or funding outside our community then we may not function and that’s the policy we have. We told most of the support groups these are just there to help, the problem is ours, it is not CRAIDS, it’s not for Family Trust and it’s not for the district.” (Community representative)