HIV/AIDSIFAD strategy paper on HIV/AIDS for East and Southern Africa

Section IV - Operationalizing IFAD's Response to HIV/AIDS

AIDS73. One factor that sets HIV/AIDS apart from other illnesses and should be mentioned at the start of any discussion of measures responding to the epidemic is the HIV/AIDS stigma. Contrary to what is often claimed, HIV epidemics, particularly in rural areas, continue to be shrouded in stigma. Negative attitudes mainly affect persons with HIV/AIDS and their families (and especially their children), but also have implications for workplaces and communities. In most countries, death from AIDS is considered a disgrace and is seldom openly acknowledged out of respect for the deceased and concern for the survivors. Stigma can therefore be a formidable barrier not only to identifying HIV/AIDS as a problem in a community but also to defining prevention, care and mitigation responses. For this reason, breaking down the HIV/AIDS stigma must constitute a key objective of any response to the epidemic.

74. Further, there is a need to shift attention from the direct effects and costs of HIV/AIDS morbidity and mortality to the broader impacts of the epidemic on the entire development process. This will require new ways of thinking and operating (Box 8). To operationalize a response to HIV/AIDS, IFAD and its partners will need to use an ‘HIV and development lensĀ“ to understand the potential and actual effects of the epidemic; and then alert project staff and others to the need to make adjustments in design and implementation procedures in order to avert or address the impact of AIDS. In some cases, this will require changes in the project design process to ensure that it reflects the needs, interests and constraints of HIV/AIDS-affected households.

Box 8: "Business as Usual?"

"… the focus is still on the direct effects of HIV and AIDS. The talk is all of prevention, caring for the sick and orphans, as though no one has realized how the virus impacts upon everything we do. It is time for governments, UN agencies, international organizations and NGOs to stop and ask: 'What were we planning to do, and are we still able to do it?' Or do we have to make adjustments, not only in our objectives but in our approach? People are calling HIV/AIDS a disaster but we are still trying to do business as usual."

Arjan de Wagt, UNICEF Nutrition Officer, cited in IFRC, 2000.

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A. Focus Areas of Response to HIV/AIDS

75. This section reviews five focus areas of response to HIV infection and the impact of AIDS: (a) target group IEC programmes for HIV prevention and AIDS mitigation; (b) poverty alleviation and livelihood security; (c) food security and nutrition; (d) socio-economic safety nets, especially for orphans and foster families; and (e) integrated HIV/AIDS workplace programmes for IFAD-supported projects.

Target Group IEC for HIVKenya - Infants undergo well baby check-ups including growth monitoring and immunizations at the IFAD/BSF.JP funded Health Centre in Narumoru, Kieni East Division. Mothers also receive counselling on issues of nutrition, sanitation and family planning. IFAD Photo by Giacomo Pirozzi Prevention and AIDS Mitigation

76. In most of East and Southern Africa, it is widely believed that rural populations are ‘aware’ of HIV/AIDS and that this knowledge is enough to initiate behaviour changes and prevent the spread of the epidemic. While most rural men and women in the region have indeed heard of HIV/AIDS, it cannot be assumed that all are adequately informed about the epidemic and able to act upon this knowledge. Information in rural areas is often very limited; and social, economic and cultural barriers, particularly gender barriers, are formidable obstacles to behaviour change.

77. Further, information, education and communication campaigns often do not reach poor illiterate young women and out-of-school girls, particularly in rural areas, or they are not tailored to the realities of their lives. For example, a young woman who knows that her husband could be HIV-positive will not act on, or even voice, her concern because she is economically dependent on her husband, fears losing her children or is inhibited by socio-cultural norms. An IEC campaign on HIV prevention can do little to protect this woman against HIV infection. Broader measures are needed to improve her economic status and empower her socially and within her marriage. Measures are also needed to raise her husband’s awareness of the ways in which his behaviour can place him and his family at risk of HIV infection, and to inform him of the dangers of such traditional practices as ritual cleansing and wife inheritance.

78. Given its reach into remote rural areas, IFAD is well placed to deliver, through partnerships with NGOs, targeted IEC to its rural beneficiaries on HIV prevention, including special measures for HIV/AIDS-affected households (hygiene, sanitation, nutrition, treatment of opportunistic infections, psycho-social support), and information on HIV testing and counselling.

79. One promising methodology for awareness-raising on HIV prevention among IFAD target groups has been developed by the Global Integrated Pest Management (IPM) Facility in Asia and tested by the FAO/Community IPM Programme in Cambodia (Box 9). The Programme took the methodology used in farmer field schools and extended it to farmer life schools (FLS). While the former use agro-ecosystem analysis to further farmer’s understanding of crop cycles and pest management, the latter use human ecosystem analysis to identify factors that influence household and community economy, health, education, social relations, culture and the environment. HIV/AIDS is one of the topics covered.60

  Box 9: From Rice Field Ecology to Human Ecology and HIV

Farmer life schools are based on the learning cycle and training methodology of the IPM farmers field schools. Like the field schools, which meet once a week, farmers life schools also meet regularly. Their activities include visits to families, presentations, discussions on special topics and group dynamics. These activities help farmers to recognize and analyse the interrelated elements of their lives, in much the same way as they apply their mastery of ecological concepts to their fields.

In farmers life schools, farmers examine problems that threaten their livelihoods, weigh available options and make decisions about what action they should take. The issues they address range from poverty, loss of land and occupational health issues (e.g. the hazards of pesticide use); to family planning, alcoholism, domestic violence and their children's schooling; to specific health concerns such as dengue, malaria and HIV/AIDS.

Source: FAO, 2000.

 

80. The FLS approach seeks to raise awareness among farmers through a dynamic learning process rather than by a top-down teaching exercise. Instead of being taught what their problems are, farmers learn how to identify and analyse their problems themselves. This learning process empowers rural men and women and can be instrumental in encouraging behaviour change. Similarly, IPM training methodology focuses on training trainers in facilitation skills and problem-solving analysis rather than on fixed messages to be delivered to the farmers. This methodology can be tested in IFAD-supported projects in Kenya, the United Republic Tanzania, and Uganda, which are currently working through farmer field schools, and then be extended to other projects.

81. Building target group awareness can extend beyond IEC HIV prevention campaigns. Rural communities need to have a central role in developing an understanding of the mechanisms fuelling HIV epidemics in order to mobilize efforts for the mitigation of AIDS impact. The urgency that surrounds IEC HIV prevention campaigns needs to extend to mitigation through complementary IEC AIDS mitigation campaigns. These can include IEC on:

(a) sustaining household productive capacity and productivity in the context of the impact of AIDS;

(b) planning within the family for young adult mortality (drawing up wills to ensure that widows and their children, regardless of sex, can inherit property; keeping children in school, etc.); and

(c) planning with the community for the impact of AIDS (capacity-building to help communities and community-based organizations (CBOs)/NGOs to conduct HIV/AIDS impact assessments and prepare microproject proposals for submission to IFAD-supported projects).

82. IFAD is well placed to undertake such IEC AIDS mitigation campaigns through its partnerships with NGOs. IFAD projects can carry out IEC campaigns on AIDS mitigation within the framework of their community development components. Using PRA, communities can assess current impact, anticipate future impact and identify potential interventions. Capacity-building to enable communities to prepare microproject proposals should accompany AIDS mitigation campaigns so that awareness-raising becomes part of a more comprehensive package of community response to HIV/AIDS. The involvement of communities, to the greatest extent possible, in the design and conduct of AIDS mitigation campaigns is essential and cannot be stressed enough.

Poverty Alleviation and Livelihood Security

83. Through its projects in rural areas, IFAD is also in a good position to engage in HIV prevention that goes beyond IEC campaigns to address the co-factors of vulnerability to HIV infection, and particularly poverty and livelihood insecurity. As argued earlier, poverty makes people vulnerable to HIV infection and the impact of AIDS by stimulating distress labour migration, threatening people’s livelihoods, pushing some women into survival or commercial sex, and reducing access to health services. Poverty alleviation and livelihood security interventions can thus play a catalytic role in stemming the spread of HIV and reducing the impact of AIDS.

84. Recent IFAD field diagnostic work in Zambia identified HIV/AIDS as the principal threat to rural livelihoods in the Northwestern Province. In the Southern Province, HIV/AIDS-induced morbidity and mortality ranked fourth among threats to rural livelihood systems, after livestock disease, repeated drought and the decimation of assets in response to drought.61

85. IFAD-supported projects offer a range of poverty alleviation components that can help to mitigate the impact of AIDS, including income-generating activities, microfinance projects and functional literacy (FAL) programmes for adults.

(a) Income-generating microprojects can improve the livelihood security of households with chronically ill adults, provide income-earning opportunities for asymptomatic persons living with HIV so that they can support their families, and strengthen socio-economic safety nets.

86. To date, income-generating projects designed to mitigate the impact of AIDS have mostly targeted persons living with HIV/AIDS. The record of such projects has been relatively poor. In Uganda, for instance, a goat-rearing scheme for this group brought no benefits since it took at least two years before they could sell the goats, by which time many farmers had fallen sick or had died. A revolving fund for income-generating microprojects also performed poorly because the loans were too thinly spread among too many members.62

87. One reason these projects have not been effective is that they fail to reflect the needs and constraints of the lowest stratum of the poor and the dynamics of the impact of AIDS. In particular, the poorest groups, often disproportionally affected by the epidemic, do not take part in the design of the projects and are least able to participate in and benefit from their activities.

88. Income-generating microprojects can even exacerbate the vulnerability of HIV/AIDS-affected households. One example is a zero grazing heifer project in Uganda, which provided families with an expectant cow so that they could benefit from milk production. The family was given full ownership of the cow once it had given birth to a female calf, which was subsequently taken away to continue the cycle. "While the project was a success under loan circumstances," an evaluation report argues, "an indivisible item such as a cow may actually increase vulnerability if the recipients are forced to make a distress sale when faced with calamity."63 The conclusion was that "the running costs, the need for veterinary services, and the need for water in a largely dry area, combined with the overall labour-intensiveness of this activity, all make it an impossible project for the poor".64

89. In view of these experiences, IFAD-supported income-generating projects may need to define criteria for activities aimed at families directly or indirectly affected by HIV/AIDS so as to ensure that the intended beneficiaries can reap benefits from these projects relatively quickly (in less than six months) and that the projects do not inadvertently increase their vulnerability. The projects should also target households that have recently suffered from young adult mortality and households fostering orphans. Working in partnership with NGOs that have some experience in income-generating projects for affected households, such as the Agency for Cooperation and Research in Development (ACORD) in Uganda and UWESO, is likely to be the most effective way of incorporating such components in IFAD-supported projects.

(b) Microfinance projects can strengthen the coping strategies of households with persons in the asympomatic stage of HIV infection by helping to ‘buy time’; and to a lesser extent, they can alleviate impact in households with persons in the last stages of the disease. They are also critical for rehabilitation purposes, for instance, to provide medium-term support to households fostering orphans (Box 10), as will be seen through the example of UWESO below. Thus, IFAD, which works closely with microfinance institutions (MFIs) in various East and Southern Africa countries, can help tailor MFI services and products in view of the impact of AIDS.

 

Box 10: Microfinance in the Fight Against HIV/AIDS

Microfinance is most useful to households before they are deeply affected by AIDS, when they can still make use of the loans and can still save money. Microfinance services can help HIV-affected households to strengthen economic safety nets that they will need to draw upon later. By focusing on women, moreover, microfinance can also play a role in reducing vulnerability to HIV/AIDS by keeping women and their daughters away from high-risk behaviours created by economic necessity.

Once AIDS gains a foothold in a household, the role of microfinance changes to primarily one supporting the productive activities of healthy family members: those who care for the sick and for any orphans living with the family. In this situation, as long as the household undertakes income-earning activities, there may be a role for loan services to help these activities along. The greater the ability of the household to maintain an income stream during this period, the more likely they are to withstand the economic devastation of the disease without selling land or other assets, taking children from school, or breaking up the family.

Finally, after AIDS sweeps through a family, survivors (often grandparents and older children) must rebuild the economic base of the remaining household. As these individuals prepare households to take on the tasks and risks of entrepreneurship, microfinance may be able to play a role in supporting their efforts.

Source: Parker et al., 2000.

 

90. In fact, there is a growing consensus that MFIs need to adjust their services and products to the changing conditions of an increasing number of their clients. Initial survey findings on microfinance and HIV/AIDS carried out by the United States Agency for International Development (USAID) in 2000 (based on the responses of 22 MFIs from across Africa) show that MFI clients are under extreme economic stress due to the HIV epidemic. Medical expenses are their greatest economic stress (95%), followed by feeding the family (86%), paying for funerals (77%) and caring for orphaned children (50%). In response to these challenges, MFIs reported the following trends over the last 12 months: (a) increased difficulty in loan repayments (57% of MFIs); (b) increased requests for access to compulsory savings (47%); (c) higher client absenteeism at meetings (45%); and (d) increased requests for smaller loan sizes (29%). Defaults were also reported to be on the rise due to HIV/AIDS.65

91. In view of the above, MFIs may need to go beyond their traditional role and offer additional services to their clients, including health services (such as information on HIV prevention), legal advice to women on inheritance and children's rights; counselling; and training in caring for sick family members. If provided through strategic partnerships, these services may be channelled to clients at minimal or no additional burden to the MFI. MFIs can also improve the fit of financial products to meet the needs of HIV/AIDS-affected households more effectively. This may involve reducing compulsory savings requirements (often required as collateral for microcredit), which may be out of reach for households with chronically ill young adults; relaxing the conditions under which clients may make withdrawals from compulsory savings accounts for health emergencies; and showing greater flexibility on loan sizes and payment schedules. As clients become sick, MFIs could also consider allowing adolescents to take over the business and the loan for a sick parent-under the guidance of an extended family member.66

92. Further, MFIs could add new financial services to their portfolio, brokering relationships with burial societies, creating trust funds or linking clients to insurance. It should be stated, however, that health and life insurance is rare in the context of HIV/AIDS as the necessary premiums are generally too costly for poor households to bear.67

93. A number of MFIs in East and Southern Africa are pilot-testing or implementing innovations — both financial and non-financial. One is the Foundation for International Community Assistance (FINCA) in Uganda. FINCA has developed various products in response to the health concerns of its clients, including health insurance, savings plans, life insurance and AIDS prevention education. Another is Opportunity International, an MFI operating across Africa, which has developed four financial products and two non-financial services in response to HIV/AIDS: mandatory loan insurance, mandatory death benefit insurance, emergency loans, education trusts for minors, HIV-prevention programmes and legal services (Box 11). IFAD could further test these innovations, and adopt successful ones in projects it supports.

 

Box 11: MFI Innovations to Mitigate the Effects of HIV/AIDS

Opportunity International (OI), a microfinance institution which involved in microfinance in Africa since 1992, currently serves more than 30 000 clients. In response to HIV/AIDS, it offers the following products and services to address the health concerns of its clients:

Mandatory loan insurance: OI charges clients a one-time fee of approximately USD 0.30 that covers loans outstanding in the case of client death. This fee mitigates the impact on affected households, since the MFI assumes responsibility if a client dies.

Mandatory death benefit insurance: One OI partner, a local insurance company, offers clients death benefit insurance that covers burial and related costs for clients and up to five dependents. OI earns commission income on each of the insurance policies purchased by clients, which covers processing costs. The insurance will be offered to solidarity groups and will cover participating members and five dependents for a maximum benefit of USD 167 per household. Clients will pay a monthly premium of USD 1.50. Purchase of insurance will be mandatory for clients, although the MFI is trying to find ways to provide it on a voluntary basis. There are no exclusions for clients with AIDS.

Emergency loans: OI is now considering ways to offer loans to clients to deal with health-related and other emergencies.

Education trusts for minors: OI is examining ways to establish an education trust to allow clients to make payments into a trust fund that could be accessed as an annuity at a later date for educational purposes.

HIV/AIDS prevention programmes: In 1999, OI initiated efforts to disseminate AIDS prevention information to its clients through partnerships with NGOs such as the AIDS Information Centre in Uganda and the Society for Family Health in Zambia. These NGOs raise awareness on health issues through peer education at weekly meetings, which clients are required to attend.

Legal services: OI works with organizations that provide legal advice on issues such as wills and inheritance laws for women, to ensure that women and children will have full legal protection after a husband/father dies. OI offers these services through strategic partnerships with groups such as the National Society for Advancement of Rural Women in Uganda, the Legal Resources Foundation of Zimbabwe and the Zambian Legal Aid Foundation.

Source: Parker et al., 2000, p. 5.

 

(c) Functional adult literacy programmes: IFAD participatory rural appraisals in Uganda have shown that FAL classes are "one of the most effective means of empowering women to learn and to acquire self-confidence".68 They also have a very positive impact on women’s lives. "Women acknowledge that functional adult literacy classes have an important role in empowering women and reducing ignorance and poverty. They identified the following benefits: they gain new knowledge, learn how to read and write, generate income through modern farming methods, improve agricultural techniques and methodologies, control crop pests, improve sanitation and hygiene at household level, learn about care and nutrition of children, improve food planning and preparation, get to know each other, creating networks and forming groups, learn to work together and establish poverty reduction strategies."69

94. Thus, literacy has empowering effects that go beyond merely learning to read and write: it can foster self-esteem and self-confidence, which are necessary to introduce lifestyle changes and cope with stress more effectively. In view of these findings, FAL programmes – if linked with productive activities such as access to credit, income-generating activities and nutritional gardens – are potentially suitable entry points for HIV prevention and mitigation education. This is because such IEC activities are unlikely to be effective where women are illiterate: illiteracy tends to be accompanied by lack of self-confidence, fear of learning and fear of change. These qualities are key obstacles to behaviour change among women.

95. Illiterate women are also more likely to fear confrontation with their husbands or partners and shy away from negotiating safe sex. In addition, women whose spouses are living with HIV/AIDS can greatly benefit from the social support of a FAL group, which can also prepare them to face the impact of their spouse’s death.

Food Security and Nutrition

96. Food insecurity and malnutrition significantly contribute to people’s vulnerability to HIV infection and the impact of AIDS. Because most people with HIV in Africa are unable to get adequate nutrition, their illness progresses faster than it normally would. For persons living with HIV/AIDS, food is the single most pressing need (Box 12). Foster families with orphans often find it difficult to provide enough food for all the children they care for, and studies have shown that orphans tend to receive food of inferior nutritional value, and they are often stunted. Women in food-insecure families may engage in ‘survival sex’ to obtain a meal for their children.

   
Box 12: Not care, not drugs, but food

Some weeks ago I was in Malawi and met with a group of women living with HIV. As I always do when I meet people with HIV/AIDS and other community groups, I asked them what their highest priority was. Their answer was clear and unanimous: food. Not care, not drugs for treatment, not stigma, but food.

Source: Piot, 2001.

 

97. The challenge for IFAD-supported projects is to find ways of breaking the vicious cycle linking food insecurity, malnutrition and vulnerability to HIV/AIDS. In certain contexts, this can be achieved through innovations or adaptations in the area of food production, food security and nutrition, rather than through HIV/AIDS-specific measures. Innovations can include:

  • Increased agricultural productivity through better crop management and the introduction of high-yielding, weed/pest-resistant plant varieties that require less labour. One example is IFAD’s recent introduction of a cassava variety in Uganda that is resistant to mould disease.
  • The rehabilitation of certain staple food crops, such as sweet potato and cassava, from ‘hunger crops’ to main subsistence crops These crops, which are often not in the mainstream of agricultural research programmes, have been found to be indispensable for the food security of households affected by HIV/AIDS. They require resources for research and extension, which IFAD-supported projects can provide.70
  • Improved agricultural practices to save labour and capital, including intercropping to reduce weeding time, and zero or minimum tillage to reduce the need for high-cost ploughs and oxen.
  • Labour- and time-saving agricultural and household technologies. These may include lighter ploughs that can be used by youths, women and the elderly; and cultivators and other tractional implements adapted to donkeys or other animals. Access to potable water and fuel-efficient stoves, for instance, can free women with an added caring burden for agricultural and other productive activities and greatly alleviate their workload. Experience with such innovations has been mixed, however. For example, in Uganda, the use of donkeys has been successful in some areas (including Rakai District), but socio-cultural norms have inhibited their effectiveness in others (such as Mbarara District), and the stony terrain has also precluded their use for cultivation.71 Similarly, ACORD’s experience with using fuel-efficient stoves in Uganda has been mixed. The type of stove promoted (twin fireplace fitted into a brick platform) proved to be unsuitable (it required a well-roofed and spacious kitchen and was costly).72 Thus, improved technologies need to be context-specific and should be tested for their physical, agro-ecological and cultural relevance before being introduced.
  • The promotion of small ruminants for consumption, sale and manure. Animal protein is an important element of any healthy diet, but is nutritionally essential for people living with HIV/AIDS. Alternatively, small ruminants can be raised for sale. Moreover, studies in the Bukoba District of the United Republic of Tanzania have found that the declining role of cattle in farming systems (resulting in part from AIDS-induced destocking) has created a severe problem for farmers: the loss of manure, which is vital in combating acidic soils. Less labour-demanding small ruminants or an enhanced availability of bio-fertilizers can help overcome problems arising from lack of manure.73
  • Nutritional gardens. These have been found to be effective in increasing household food security. Furthermore, because of their proximity to the homestead, they are a feasible activity for women with an added caring burden. They also yield quick benefits.
  • Nutrition education. Nutrition education conducted by community-based workers, agricultural extension staff and NGOs is needed to inform households of the importance of nutrition in prolonging lives of chronically ill adults and promoting the healthy development of the entire household.
  • Improved labour exchange arrangements through community mobilization and organization. Experience in Rakai and Masaka Districts in Uganda shows that labour-sharing clubs have been effective in relieving labour shortages and in alleviating the impact of AIDS.
  • Improved access to demand-driven agricultural extension services that address the felt needs of men and women farmers, including those affected by HIV/AIDS. Priorities must be: (a) to improve access to agricultural extension services for young widows, the elderly and child-headed households; and (b) to adjust these services to factor in the effects of young adult morbidity and mortality (including labour shortage, lack of cash for agricultural inputs and decimation of the asset base). This may require a review of existing approaches, typologies of farm households, and communication strategies and materials.
  • Small changes in gender roles and in resource allocation among households and communities can have a positive impact on food security in HIV-affected households. Since the burden of caring for HIV/AIDS patients usually falls on women, such details as whether women are allowed to ride bicycles and whether bicycles are available can be important determinants of the marketing capacity of an affected household or community. Gender roles also influence the continuation or adoption of labour-saving responses (for example, the use of oxen or access to land and/or credit).74

98. It is often mistakenly assumed that projects supporting staple food crops, small ruminants, nutritional gardens and labour-saving technologies are self-targeting both to HIV/AIDS-affected households and to women. Households headed by young widows with many young, dependent children or households headed by elderly grandmothers often face severe labour constraints and may not have the time or the opportunity to participate in project activities. Projects need to reach out to them, creating an enabling environment that takes account of their needs and constraints. Moreover, since men control resources in most parts of Africa, the actual division of labour and pattern of access and control over resources need to be verified when designing a project.75 This is particularly important in that the impact of AIDS disproportionately affects women’s access to resources.

Socio-Economic Safety Nets

99. Although orphan support is not a traditional concern of agricultural investment projects, the magnitude and tragedy of orphanhood in East and Southern Africa have far-reaching implications for the socio-economic development of every country in the region. As seen earlier, in some countries, one in four households is affected by orphanhood directly, while many others are affected indirectly. Development and poverty alleviation strategies, which so far have largely ignore this trend, therefore need to transcend traditional boundaries and address this most urgent crisis.

100. The following section focuses on IFAD’s most effective mitigation intervention to date: its support to orphans and foster families through the Uganda Women's Effort to Save Orphans. What is unique about UWESO is that it began as a relief operation assisting war orphans and evolved into a development programme aimed at strengthening the extended family, which is bearing the brunt of the HIV epidemic in general and orphan care in particular. The UWESO experience is thus valuable as a model for other IFAD-funded projects concerned with supporting socio-economic safety nets, and could also be replicated in other countries with high orphan tolls.

Case Study: IFAD Support To Orphans and Foster Families

101. The Uganda Women's Effort to Save Orphans is a non-profit NGO concerned with improving the lives of orphans by empowering local communities to meet the social, economic and psychological needs of these children. It was started in 1986 by Janet Museveni, wife of President Yoweri Museveni, to provide food, clothing and blankets to orphans in war-torn areas and return children to their extended families. Under the severe impact of HIV/AIDS, however, UWESO’s focus was widened to include direct welfare to AIDS orphans.

102. The task of orphan support in Uganda is formidable: there are currently 1.7 million orphans due to war and HIV/AIDS, while about a quarter of all households in the country are fostering orphans. In view of the magnitude of the orphan crisis, UWESO’s direct support in the form of school fees and the provision of basic needs was proving to be limited, expensive and unsustainable. For this reason, UWESO shifted to strengthening the social safety net that has traditionally supported orphans of war, disease and natural calamity: the extended family.

103. With financial and technical support from the Belgian Survival Fund and IFAD, the UWESO Development Project was designed in 1994. The project provides training to both foster families and adolescent orphans, giving them the knowledge needed to run small-scale income-generating projects. It also provides the required resources through a loan scheme, known as the UWESO Savings and Credit Scheme (USCS).

104. Most of UWESO’s 10 000 volunteers are middle-aged women (grandmothers, aunts and older sisters) who are widowed. On average, each woman cares for seven orphans. To ensure the elimination of stigma and promote positive living and respectability, UWESO offers support to caregivers without singling out AIDS orphans. Yet, over 90% of USCS clients are caregivers of AIDS orphans.

105. USCS clients generally run small businesses: buying and selling produce, fish mongering, baking and selling bread, retailing essential commodities (charcoal, salt, sugar, soap, match boxes, paraffin), selling bicycle spare parts, operating small restaurants, brewing beer or managing bicycle taxis.

106. One of the project’s main pillars is its comprehensive training programme. After the initial selection of a sub-county, training commences through public rallies in different parishes.76 The rallies give UWESO staff the opportunity to identify parishes committed to the programme (determined through attendance).

107. During the training period, clients are encouraged to start saving money, which will be deposited in group savings accounts. The next stage of training involves group formation and the use of the group as guarantor or security for individual loans. Groups of five to seven persons are formed, and the leaders (chairperson, treasurer and secretary) are elected.

108. In pre- and post-loan training periods, other additional components are usually added to micro-savings operations, including: (a) agricultural modernization, improvement of farm output, nutrition, bee-keeping and zero-grazing; (b) women’s rights and legal aid (legal status of women and children with regard to property and inheritance); (c) family planning; (d) management of adolescent orphans; and (e) treatment of malaria among pregnant women; and (f) child immunization.

109. USCS has led to: (a) improved nutrition; better access to health care, clothing and children’s education; and improved living and housing conditions (with many homes being upgraded from temporary to permanent in some districts); (b) a sounder economic base for USCS clients, including a culture of savings; (c) empowerment through knowledge, self-confidence and leadership skills; (d) income diversification among USCS clients; (e) a reduction in dependency on handouts.

 

Box 13: Restoring Livelihoods with the Help of the USCS

When Mary was 15, her father died after a long illness. Two years later, she and her brothers dropped out of school for lack of school fees. Six months after that, in 1993, she married and now has four children.

Mary joined USCS in 1997 to help support her ageing mother and pay school fees for her brothers, three of whom had not yet started school even though they were over-aged. With hard work and group savings, Mary is now operating a number of interlinked small businesses. She and her husband have expanded their shop, once near collapse, and are now running a restaurant from their living-room. In addition, they rent two spare rooms, which are occupied on average four times a week. In the evenings, they sell roasted goat meat.

Together with her husband, Mary also bought two acres of land to add to the 1.5 acres they already own. Since they have recently acquired five head of cattle from the UWESO savings and credit scheme, they use the new land for cattle grazing. On their original plot, instead, they cultivate groundnuts, potatoes, millet, peas and matooke (occupying about one acre). All the matooke they produce has a ready market - her restaurant. Mary also has a contract to cook lunch for six teachers in a nearby school.

Due to a water shortage in the area, Mary and her husband built a brick and concrete water tank, from which they sell the surplus water harvested from the roof of their shop.

Mary is able to meet the financial demands of her mother, her siblings (all of whom are now in school) and her children. She is also a member of the Ngarama People's Trust a local micro-savings operation started by UWESO clients a year ago. She has six shares in the trust and has savings amounting to Uganda Shilling 250 000 (USD 168) with UWESO.

 

110. For out-of-school orphans, UWESO has set up an apprenticeship programme through community artisans. The programme is designed for orphans who are unable to complete elementary school, usually because they are needed at home to care for their younger siblings. Through the UWESO Savings and Credit Scheme for Orphan Entrepreneurs, village artisans (near the orphan’s homes) teach skills such as carpentry, bricklaying, concrete-mixing, metal-works, tailoring, catering, hairdressing, and bicycle, radio and TV repair. Orphans receive on-the-job training and earn as they learn. After this training, they are introduced to micro-business management and subsequently become eligible to take out loans to start their own micro-businesses. These small businesses are of critical importance to child-headed households, as they often become their sole source of income.77

111. Micro-savings operations, which yield quick benefits for households fostering orphans, contribute to the success of UWESO. "It is microfinance with a difference," says UWESO Executive Director Pelucy Ntambirweki. "Banks do not deal with grandmothers and widows. They bombard them with paperwork and want them to write and sign things. We designed savings and credit programmes that work for families in these situations, and we have taught them how to manage, how to use a loan, how to save."78

112. UWESO now has 36 branches working in 15 districts throughout Uganda and has reached about 100 000 orphans. However, as Ntambirweki argues: "We have helped 100 000 children, but despite all our efforts, that is still only 5% of those in need."79 Given that community-based care is the only sustainable response to orphanhood (as opposed to institutional orphan care), initiatives such as UWESO are vital and in urgent need of replication across East and Southern Africa to mitigate the impact of AIDS on the millions of children orphaned by the epidemic. Using the UWESO model and its experience, IFAD projects can introduce activities aimed at supporting socio-economic safety nets (savings and credit schemes for foster families, and training and artisan programmes for orphans).

Integrated HIV/AIDS Workplace Programmes for IFAD-Supported Projects

113. HIV/AIDS workplace programmes for IFAD-supported project staff should aim to address: the vulnerability of project staff to HIV infection and the impact of AIDS (in terms of access to information on HIV/AIDS and to safe working conditions); the relevance of existing workplace benefits and human resource procedures; and the technical capacity of staff to deal with HIV/AIDS concerns in their work.80 The following aspects thus need to be included in HIV/AIDS workplace programmes:

(a) IEC on HIV prevention, care and support. Although it is recognized that development project staff are as vulnerable as other people to HIV infection, it is often assumed that they are sufficiently infomed about HIV prevention, care and support. Such assumptions can be misleading. Misconceptions about the disease abound, stigmatization may be pronounced and prejudices strong, while on-the-job discrimination is a reality for a number of project staff and their families living with HIV/AIDS. This tends to be the case particularly for support staff (drivers, messengers, guards and secretaries) who are often excluded from IEC campaigns and are more vulnerable socio-economically.

(b) Review and adjustment of project staff working conditions. Certain working conditions may inadvertently expose project staff to high-risk situations. For example, project staff members who are required to travel extensively for their work and are often separated from their families are at high risk of HIV infection. This includes not only professional managers and technical staff but also some support staff, such as drivers.

(c) Review and adjustment of administrative procedures and human resource policies. Terms for sick leave, unofficial leave, emergency advances and other procedures may need to be reviewed, and recruitment and replacement procedures adjusted.

(d) Capacity-building and training in the technical aspects of the impact of HIV/AIDS. Staff members may not have the capacity or know-how to respond to the technical implications of HIV/AIDS for their area of expertise (e.g. the implications of labour shortages for agricultural research and extension).

114. This strategy paper, therefore, extends the usual definition of HIV/AIDS workplace programmes to encompass more than IEC for HIV-prevention initiatives and programmes to combat discrimination. HIV/AIDS workplace programmes provide an opportunity to address the cross-sectoral impacts of the epidemic in a single ‘package’, which could include:

  • Raising awareness of project staff (at all levels) and their families of HIV prevention, care and support;
  • adopting policies to break down stigmatization, promote acceptance and support project staff living with HIV/AIDS, protect their rights and prevent discrimination in the workplace;
  • ensuring staff access to HIV testing and counselling;
  • making provisions for the care and support of project staff living with HIV/AIDS, and their families;
  • adjusting working conditions of project staff exposed to high-risk situations (e.g. trying to ensure that project staff’s families live with them at their duty stations; and limiting the number of overnight stays for project employees, including the number of seminars, workshops and training courses requiring absence from their home bases);
  • multi-skilling at all levels supported by training strategies;
  • adjusting benefits and/or administrative procedures (e.g. recruitment and replacement, sick leave, unofficial leave) to take account of the impact of AIDS, in collaboration with public service commissions or equivalent bodies;
  • providing alternative social security options (such as health care schemes and welfare funds to assist HIV/AIDS-affected staff members and their families);
  • arranging for staff training on the impact of HIV/AIDS on rural households; and on the linkages between HIV/AIDS and the core technical areas of project work and their implications for project implementation (e.g. how to help households sustain their productive capacity despite labour shortages, asset depletion and the increased need for food and income);
  • appointing an HIV/AIDS focal point from the project staff with precise and agreed upon terms of reference and informing staff about his or her role and responsibilities;
  • carrying out advocacy campaigns to elicit political commitment for HIV/AIDS at the highest ministerial levels;
  • preparing an action plan for the integration of HIV/AIDS concerns into the project workplan and budget;
  • formulating communication strategies for project staff, partners and target groups to ensure that appropriate HIV/AIDS messages are delivered to each stakeholder; and
  • carrying out action research on specific the impact of HIV/AIDS and relevant mitigation measures, as identified by project beneficiaries.

115. The choice of appropriate interventions from this range of activities will vary considerably from project to project and from country to country. The list above provides a broad framework on the basis of which individual projects can design HIV/AIDS workplace programmes tailored to their needs.

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B. Incorporating HIV/AIDS in the IFAD Project Cycle

116. During fieldwork conducted for the preparation of this strategy in Uganda and Zambia, it became apparent that HIV/AIDS concerns and response measures need to be explicitly spelled out in the project design phase and incorporated in the project document in order to address the spread and impact of the epidemic effectively.

117. For example, staff of VODP in Uganda were very much aware that, either directly or indirectly, HIV/AIDS is affecting "each and every household in the country", in the words of the acting project manager. They recognized the importance of incorporating HIV/AIDS mitigation activities into project work, even if this meant adding onto the existing workload. They had not thought of HIV/AIDS in terms of how it related to project work, however, because, they argued "it is not in the project document". The underlying assumption is that since projects aim to reduce poverty, they de facto target households affected by the HIV epidemic, and no deliberate efforts are therefore needed to do so.

118. A major constraint to integrating HIV/AIDS concerns in project work is the absence of implementation guidelines. As one IFAD-supported project manager in Zambia admitted: "We don’t know how to [address HIV/AIDS]-–show us [how] and we will do it."

119. These observations point to the need for a systematic integration of HIV/AIDS concerns into the IFAD project cycle, which extends beyond problem analysis to the identification of concrete entry points and response measures. In project areas severely affected by HIV/AIDS, further conceptual and operational adjustments may also be necessary. Such a process needs to run through the entire project cycle from the country strategic opportunities paper (COSOP) to project completion. Some examples of how HIV/AIDS concerns can be integrated into each stage of the project cycle are provided below.

Project Design

120. HIV/AIDS concerns should start at project formulation. Key stakeholders need to be involved in the identification and planning of measures responding to the impact of AIDS on livelihoods, communities and socio-economic safety nets, and on proposed project activities.

121. Further, project design should clearly specify institutional responsibilities for incorporating HIV/AIDS in the project cycle. Experience shows that only when there is commitment at the highest levels of government, project management, etc., will HIV/AIDS concerns be taken seriously. Thus, while an HIV/AIDS focal point within projects in areas heavily affected by the epidemic can help coordinate HIV/AIDS response measures, overall responsibility for integrating HIV/AIDS concerns in project work should rest with the project manager or coordinator. Otherwise, there is a risk that HIV/AIDS will be perceived as a separate component and that it will not become an integral part of all aspects and phases of project work.

Country Strategic Opportunities Paper

122. The COSOP, prepared by IFAD in close consultation with governments, provides an analysis of the overall country situation, with emphasis on the rural poverty context. It is the basis on which IFAD delineates short and medium-term investment strategies for the country. Since the COSOP is the framework for the identification of investment priorities, it is important that the implications of HIV/AIDS for agricultural and rural investment projects feature prominently in this document. In particular, as pointed out in Box 14, rural poverty analyses will need to take into account the burden of disease, as the characteristics of rural poverty may change considerably under the impact of AIDS. Proposed poverty alleviation strategies may need to be adjusted accordingly. In some cases, IFAD’s strategic thrust in highly affected countries may also need to be reviewed. Finally, the COSOP can also serve to elicit political commitment for HIV/AIDS at the highest levels of government.

 

Box 14: Integrating HIV/AIDS in the Uganda COSOP

In its analysis of the poverty situation, the 1998 Uganda COSOP identifies AIDS as a contributing factor to rural poverty: "The AIDS epidemic has depleted the supply of able-bodied persons between the ages of 18-45 years and this problem continues to affect individual families and overall agricultural productivity." This analysis needs to be taken further: the impact of the depleted rural labour supply on households and on agricultural productivity, and their implications for IFAD project design and implementation, need to be explicitly spelled out to ensure that HIV/AIDS concerns are incorporated in each phase of the project cycle.

Further, assumptions about the characteristics of rural poverty based on ten- or even five-year-old data may no longer be relevant in countries heavily affected by HIV/AIDS. For instance, this COSOP does not explicitly take into account how the impact of HIV/AIDS may have modified the main characteristics of rural poverty in Uganda, which are identified as follows:

"(a) the rural poor grow proportionately the same amount of cash crops as the non-poor and proportionately more coffee in the central region; b) over 80% of households spend two thirds of their total expenditure on food; c) over 20% of non-food expenditure is spent on education and health; and d) for the bottom 25% of households, over 20% of total income is provided by remittances." In the context of HIV/AIDS in Uganda, where epidemic impact peaked in the early 1990s, and given labour shortages and income declines, it is unlikely that households headed by women, the elderly and youths have been growing the same amount of cash crops as the non-poor. Moreover, many households with chronically ill adults spend most of their income on medical expenses rather than on food. In brief, the profile of rural poverty in Uganda has changed considerably as a result of the impact of AIDS, and these changes need to be reflected in poverty situation analyses. In addition, these changes may warrant adjustments in IFAD's overall poverty alleviation strategy in the country.

In terms of entry points for HIV/AIDS concerns, the COSOSP indicates that "there is a need to develop extension approaches and methods suitable to the changed economic and institutional framework of the country". Since one of the factors contributing to the changed framework is HIV/AIDS, this is particularly relevant. AIDS-induced changes in the clientele of agricultural extension (the elderly, women and youths), and their needs (technology, knowledge, etc.), interests and constraints, need to be taken into account.

Specific guidelines generated from IFAD's experience in Uganda are also relevant in the context of HIV/AIDS. For instance, the COSOP mentions that "project design should allow sufficient flexibility for the project to adapt to changing circumstances during implementation; mechanisms should be introduced to recognize and address newly emerging problems". If HIV/AIDS is recognized as such a problem, then the need for flexibility in project design can help management introduce appropriate response measures.

Source: IFAD, 1998, pp. 8-12.

 

Inception Phase

123. The inception paper enters the proposed project into the IFAD programme pipeline. Building on the strategic thrusts outlined in the COSOP, it defines the scope of the planned project. In the event of changes in the political, economic or social situation as originally defined in the COSOP, the inception paper will address these changes and their implications for the proposed investment. This paper should also include the HIV/AIDS strategy to be adopted within the framework of the proposed project. In particular, HIV/AIDS concerns should be factored into the poverty alleviation strategy pursued in highly affected countries, and AIDS should be specified as a contributing factor to food and livelihood insecurity, with appropriate response measures clearly defined.

Project Identification Phase: Socio-Economic Production Systems Studies

124. For socio-economic production systems studies, IFAD missions carry out participatory needs identification and analysis with potential project beneficiaries, during which contacts are also made with possible NGO and donor partners. At this time, they also assess the socio-economic and cultural environment. During the project preparation cycle, IFAD routinely carries out baseline surveys or similar activities, but generally does not pay much attention to HIV/AIDS in these exercises. Baseline assessments should include an analysis of the potential effects of HIV/AIDS on the proposed project (and vice versa), ongoing HIV prevention and mitigation activities in the proposed project area and potential partners.

 

Box 15: Factoring HIV/AIDS in Inception Papers

The inception paper of the

Dry Area Smallholder and Community Services Development Project (CKDAP) illustrates why HIV/AIDS needs to be included in the poverty profile, in potential project components and in project design issues. In the mid-1980s, IFAD made a "concerted effort to establish the location of the poor in Kenya, understand the root causes of their poverty and target IFAD assistance accordingly". The main finding of this exercise was that poor smallholders exist in both high and medium-potential agricultural regions and in the arid and semi-arid areas of the country. In the high and medium potential areas, poverty was found to be largely a result of high population density and an associated lack of agricultural land. While these findings may have been valid in the 1980s when this poverty analysis was undertaken, many areas of Kenya have since been severely affected by the HIV epidemic. Thus, there may be a need to re-examine some of these findings, especially considering that they are being used as the basis of important design decisions.

Further, the analysis of the project's probable impact on health does not mention HIV/AIDS, even though improving the health status of the population is a project objective and key component. This is a fairly common but major omission, as it cannot be assumed that projects addressing health issues are in fact taking HIV/AIDS into account.

Source: IFAD 2000a.

 

125. Such preparatory activities should also determine the policy environment as it relates to HIV/AIDS and community perceptions of the effects of the epidemic on their livelihoods, including current and potential community HIV prevention and AIDS mitigation strategies. The participation of NGOs could be initiated at this stage, drawing on their experience in HIV/AIDS and community development. Participatory methodologies that involve the beneficiaries in carrying out HIV/AIDS risk assessment and HIV prevention are also likely to serve as prevention and mitigation activities.

126. In order to assess vulnerability to HIV/AIDS and determine where the focus of response should lie, the vulnerability and mitigation matrix proposed in Section III.B can be used during baseline work. Further, in highly affected areas, an exercise akin to environmental assessments could be carried out as part of the socio-economic and production systems survey (SEPSS) in order to classify the project and its various components as they relate to HIV/AIDS risk. Risk would be measured in terms of HIV/AIDS prevalence in the project area, the epidemic impact level and an assessment of the effects that proposed project activities could have in this situation (e.g. road rehabilitation involves high risk; health initiatives involve low risk).

Formulation Phase

127. During formulation, a comprehensive project design is produced based on the findings of the SEPSS. Details of the project’s technical, financial, implementation and management activities are developed during this phase. Formulation reports must clearly detail how the proposed HIV/AIDS-related activities will be implemented, including training and other capacity-building requirements, to ensure that these activities will effectively be carried out. Financial and human resource requirements should be an essential part of this exercise. Performance indicators should also be identified and incorporated into the project formulation document.

 

Box 16: Participatory Rural Appraisal and HIV/AIDS

PRA exercises aiming at capturing HIV/AIDS impact need to take into account the following: (a) HIV/AIDS may not be an appropriate entry point for discussion and can be too sensitive an issue to raise directly in many communities. Poverty, household food insecurity, constraints in agricultural production and ill-health are likely to be more suitable entry points; (b) project staff trying to obtain data and information on HIV/AIDS may find it more appropriate to inquire about chronic young adult illness rather than about HIV/AIDS specifically, given the stigma surrounding the disease; (c) HIV/AIDS is unlikely to emerge as an issue from a PRA exercise unless it specifically probes into issues related to the epidemic. This has been found to be the case not only for agricultural and rural development projects but even for health projects or health components of projects.

PRAs conducted in countries with high HIV/AIDS prevalence and high epidemic impact should include daily activity calendars, time-use exercises, gender division of labour by crop, and/or asset ownership for households affected by young adult morbidity and mortality and possibly for orphans. These exercises will help identify changes in division of labour, time labour allocation, farming systems, and the roles and responsibilities of different age groups within households. Such exercises (disaggregated by gender) will also be critical in identifying, with the communities, suitable prevention and mitigation initiatives.

 

128. Programme formulation teams are composed of country portfolio managers (CPMs), technical consultants hired to formulate specific project components, IFAD technical divisions and cooperating institutions. These teams would greatly benefit from training on the policy and programming implications; of (a) the impact of HIV/AIDS on the various social and productive sectors that IFAD finances; (b) the relevance of HIV/AIDS for agricultural/rural development projects; and (c) ways of integrating HIV/AIDS prevention and mitigation activities in IFAD-financed projects.

129. As part of the formulation process, the project development team (composed mainly of selected IFAD staff) reviews the formulation report and gives technical guidance to the formulation team. Once the formulation report is complete, a technical review committee, (composed of advisors from IFAD’s technical division) and the strategic operations committee (chaired by the Fund’s President) provide technical and policy guidance. Issues arising from the technical review and strategic operations committees are addressed during the appraisal phase. To ensure that HIV/AIDS is integrated in the project formulation phase, it is essential that members of both committees are fully aware of HIV/AIDS policy issues and recognize the need for their integration in project implementation modalities and budgets.

130. The following recommendations, based on a review of the Central Kenya Dry Area Smallholder and Community Services Development Project (CKDAP) illustrate how formulation reports can incorporate HIV/AIDS concerns.81

131. HIV/AIDS adult prevalence maps can be added on to the usual repertoire of base maps, agro-ecological zone maps, rainfall maps and project division maps. Such a map will give a quick overview of the severity of adult HIV/AIDS prevalence in the project area.

132. Project logical frameworks (logframes) can include vulnerability to HIV infection and the impact of AIDS with corresponding indicators. Some logframes already include HIV/AIDS, but primarily or exclusively in a health or HIV IEC prevention capacity. The CKDAP formulation report includes a logframe where the management of STIs and HIV/AIDS is among the project activities, and a corresponding indicator is listed (number of STI/HIV prevention plans and programmes and number of activities).82 HIV/AIDS could, however, also feature among the core project activities (such as training, improvement of crop and livestock production, verification of agricultural technologies, safe motherhood and child survival).

133. Households affected by young adult mortality should be included in the target group. IFAD formulation reports often define target groups as "households that are most vulnerable to household food insecurity and to absolute poverty."83 In countries with high HIV/AIDS prevalence rates and high epidemic impact, the poorest segments of the population are likely to include many households affected by HIV/AIDS. Targeting criteria for IFAD projects may therefore need to be adjusted to ensure that households affected by young adult morbidity and mortality are specified in the target group.

134. In the case of the CKDAP, selection criteria for households developed during the design workshop included:

  • Woman-headed households
  • Households with children under five years
  • Households with small plots
  • Poor income level
  • Recipient of famine relief
  • Squatter families
  • Reliance on irregular casual labour
  • Orphans
  • Young unemployed household members
  • Distance to health and water supply facilities

135. Orphans aside, the criteria highlighted in italics could also have included households affected by HIV/AIDS if the formulation document had explicitly stated that young adult morbidity and mortality is a priority targeting criterion. Therefore, in addition to the criteria identified during the workshop, the following could be added to capture households affected by HIV/AIDS:

  • Households fostering orphans
  • Households with chronically ill young adults
  • Households that have suffered from young adult mortality in the last two years.

136. Build mechanisms in the design process to facilitate the participation of HIV/AIDS-affected households in project activities. Targeting households affected by young adult morbidity and mortality may not be enough. The project formulation process may need to consider operational adjustments that will enable such households to overcome the labour and other constraints they face. The objective of such mechanisms should be to create an enabling environment in which households can participate in and benefit from project activities.

137. Include HIV/AIDS as a factor of vulnerability to food insecurity and coping strategies. In the case of vulnerability to food insecurity, the CKDAP refers to: (a) seasonal household food insecurity (caused by frequent drought and insufficient land); (b) inefficient social services (such as water supply, health facilities and education); (c) absence of support structures (extension services and rural finance services); and (d) insecure land tenure (for squatters).84 HIV/AIDS should also be included as an important factor of vulnerability. In terms of coping strategies, the formulation report mentions women and girls being forced into commercial sex. What is far more significant and common, however, is ‘survival sex’ (see Box 4), which many more women engage in to support their families through periods of food insecurity. More generally, the inclusion of HIV/AIDS in the context of coping strategies may help piece together a more comprehensive profile of poverty and vulnerability.

138. Define the potential adverse effects of the project under preparation and particularly on households with chronically ill adults. Projects in areas with severe AIDS impact levels may need to address the following issues, including in formulation reports:

(a) Could project activities inadvertently obstruct the provision of care to the sick, to infants and young children and to orphans, and if so how? What types of safeguards are needed to prevent this?

(b) Are project activities suitable for young people and the elderly in terms of their physical, legal and skills requirements? Could safeguards be built in to ensure that these groups can benefit from project activities given the constraints they face?

(c) Could project activities inadvertently increase the risk of HIV infection, and if so what prevention and mitigation activities need to be put in place to prevent this from happening?

139. Extend beyond health-related HIV/AIDS components. Formulation reports often incorporate IEC programmes, usually in the context of primary health care sub-components. These tend to consist exclusively of STI/HIV/AIDS control activities (assisting district health teams to plan and implement strategies to monitor and control the spread of HIV, providing training in STI management, counselling and promoting condom use).85 These components should be supplemented with HIV prevention measures in the project’s core technical areas as this is where IFAD’s comparative advantage lies.

140. Address HIV/AIDS as a cross-sectoral issue. HIV/AIDS may feature in the analysis of health problems in a given project area, and may be dealt with in some detail in working papers in the annexes of formulation reports, The findings often get lost, however, within the health component of project documentation. In the case of the CKDAP, the formulation report (May 2000) included as an appendix a working paper on health, nutrition and sanitation, which clearly indicates that HIV/AIDS is a major public health and development challenge. It also reports that the five districts where the proposed CKDAP-II project will be operating have ongoing STI/HIV/AIDS-control activities and annual action plans and budgets, but that the financial resources they receive are so meagre that there are no activities at community level in any of the districts.86

141. The working paper cites the following problems associated with the epidemic in Kenya:

  • HIV infection and AIDS are rapidly increasing everywhere in the country.
  • Knowledge about the transmission and prevention of HIV is inadequate.
  • Communities do not know how to live with and support people living with HIV/AIDS.
  • Men are reluctant to use condoms.
  • Health workers are not adequately trained to counsel those living with HIV/AIDS.
  • There is inadequate empowerment of women, who are often unable to make decisions regarding their sex life.
  • Unemployment and poverty are increasing, leading to commercial sex, and the brewing and sale of illicit brews.87

If these important findings had been systematically incorporated in the main formulation report, they could have led to the identification of comprehensive HIV prevention and AIDS mitigation measures.

142. A provision should be made in the formulation report to appoint an HIV/AIDS focal point – a technical officer appointed from the staff to coordinate the integration of HIV/AIDS concerns in project work and operationalize related activities.

Appraisal Phase

143. At appraisal, issues raised at the technical review and operational strategic committees are addressed and integrated into the formulation report, which then becomes the appraisal report. This entails field missions aimed at filling in policy, implementation and technical gaps. To include HIV/AIDS concerns, cooperating institutions may need to approve annual workplans and budgets (AWP/Bs). In some instances, objections have been raised to the implementation of HIV/AIDS-related activities proposed by projects and programmes. In an IFAD-financed programme in Zambia, for instance, staff were advised by the cooperating institution not to address HIV/AIDS issues specifically but to concentrate on agriculture and other investments as detailed in the appraisal report. This highlights the fact that many of IFAD’s cooperating institutions do not operationally link HIV/AIDS with development activities.

144. The appraisal report supersedes the formulation report and is the basis of loan negotiations and eventually of project implementation.88 It is therefore of paramount importance that appraisal reports specify the identified HIV/AIDS-related interventions to be undertaken by the project, including how and through what human and financial resource facilities they will be implemented.

Approval by the IFAD Executive Board

145. Following appraisal and loan negotiations, the programme is presented to the IFAD Executive Board, which approves the programme and the loan. The responsible country portfolio manager presents the programme to the board.

146. President’s reports could briefly review the HIV/AIDS situation in the project area, link it with the project’s objectives and rationale, specify how households directly and indirectly affected by the epidemic will be targeted and reached, and specify how response measures can feature in the proposed project components (e.g. extension, research, community development, feeder roads, and rural water supplies). In heavily affected areas, sections on the impact of HIV/AIDS could be introduced along the lines of environmental impact sections. In addition, the following elements could be added to President’s reports:

  • HIV/AIDS adult prevalence rates and number of orphans in the country data annex of the reports.
  • HIV/AIDS concerns in the logical framework of the project.
  • HIV/AIDS response measures in the various project components.

Project Implementation

147. An important lesson learned from IFAD’s gender mainstreaming work is that better linkages are needed between project design and implementation in IFAD-supported projects. A wide gap often exists between what is argued in project appraisal reports and what actually happens on the ground.89 Thus, project formulation and appraisal teams need to work closely with implementing agencies to build local ownership and a common understanding of a project’s approach to preventing the spread of HIV and mitigating the impact of HIV/AIDS.

148. Within the project implementation cycle, HIV/AIDS will need to feature in the following processes:

(a) Start-up workshops: Held in-country, project start-up workshops bring together government officials, IFAD staff, cooperating institutions, donors, NGOs, and key project stakeholders, including representatives of the target beneficiaries. During the workshops, projects are officially introduced and implementation is reviewed in detail. Discussions are based on implementation manuals developed for the project and dealing with the implementation of project components; finance and accounting; procurement; and training. As such, these workshops can also serve as an entry point for discussion with stakeholders on HIV/AIDS and its implications for the project, based on the presentation of a brief paper on the implications of HIV/AIDS for project staff, operations and beneficiaries, and for operational modalities of implementation activities.

(b) Project implementation committees: To ensure that HIV is on the agenda, project implementation committees should include at least the project’s HIV/AIDS focal point and, where possible, a member from the district AIDS planning committee or equivalent body.

(c) Supervision missions: The supervision of IFAD-financed projects in the region is carried out once or twice a year by cooperating institutions (World Bank, UNOPS or the African Development Bank) contracted by IFAD. In a few cases, the IFAD country portfolio manager directly supervises some projects. Supervision missions provide technical guidance to projects and make sure that project activities and procurement are in line with the appraisal reports and with AWP/Bs. IFAD has to make sure that HIV/AIDS is on the agenda of supervision missions, and that mission members have the technical capacity to address HIV/AIDS-related issues or know whom they can call upon to provide specialized technical services. Communicating the IFAD HIV/AIDS strategy to the cooperating institutions, establishing a regular exchange with them on HIV/AIDS-related issues and underscoring the need to incorporate HIV/AIDS in ongoing and future projects and in project supervision are all therefore critical.

(d) Monitoring and evaluation: To ensure that IFAD-supported projects are reaching households affected by HIV/AIDS, many of which are likely to be among the lowest stratum of the poor, beneficiary contact monitoring should be built into management information systems and complemented by participatory evaluation.

(e) IFAD’s gender-strengthening programme in East and Southern Africa recently recommended, on the basis of its Zambia Field Diagnostic Study, that project planners and implementing agencies gather empirical information on gender roles in a particular locality, ethnic group and farming system, given the differences in gender roles and responsibilities among different ethnic populations and in different geographical areas and farming systems.90 This is particularly relevant for the design and monitoring of AIDS mitigation measures in the area of household food and nutrition security. It may also be useful to complement such data collection exercises with data that capture AIDS impact levels.

(f) Mid-term reviews: Mid-term reviews are carried out by governments or by IFAD’s Evaluation Office to assess project implementation progress and performance. The mid-term review is an important stage in which to take stock of HIV/AIDS initiatives. In some cases, mid-term reviews recommend alternative directions for the project, including reallocation of funds in order to facilitate the project’s eventual positive impact. This could be an entry point for HIV/AIDS-related activities in cases where these were not originally included.

(g) Programme termination: At programme termination, governments prepare completion reports. An evaluation could be made of how HIV/AIDS has been taken into account in project activities and of the project’s impact on the spread and impact of the epidemic in the project area and on poor households affected by young adult mortality. Completion reports could then become an important mechanism through which to document experiences, opportunities and constraints in this area.

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60/ FAO, 2000.

61/ IFAD 2000b, p. 27.

62/ UNAIDS, 1999.

63/ Ibid.

64/ Muhangi and Turinde-Kabali, 1998, p. 5.

65/ Parker et al. in UNAIDS 2001c, Appendix D.

66/ Ibid., p. 2.

67/ Ibid., pp. 2-3.

68/ IFAD, 2000c, p. 28.

69/ Ibid., p. 22.

70/ See, for instance, Rugalema, 1999a.

71/ Personal communication, Frederick Joel Wajje, Agriculture and Environment Programme.

72/ Manager, World Vision, Kampala, April 2000; and Muhangi and Turinde-Kabali, 1998, p. 7.

73/ The Lorena stove promoted by CARE has proved more successful as it is easier and cheaper to construct and is user friendly.

74/ Rugalema, 1999a, p. 199.

75/ Barnett, 1994a.

76/ IFAD, 2000b, p. xi.

77/ A parish is one of the smallest administrative groupings within the Ugandan local government system.

78/ UWESO, 2001.

79/ UWESO Executive Director Pelucy Ntambirweki, quoted in IFAD 2001, p. 39.
Ibid.

80/ Topouzis, forthcoming.

81/ The CKDAP operates in five districts, one of which, Thika District, has the highest HIV/AIDS adult prevalence in the country at 34% (1998 data). See IFAD, 2000a, Annex 1, p. 32.

82/ Ibid., p. xii.

83/ Ibid., p. 16.

84/ Ibid., p. 14.

85/ Ibid., pp. 24-25.

86/Throughout the working paper, there is important information, such as "No aggressive HIV/AIDS control activities are in place [in Maragua]. No counsellors have been trained to offer services to those infected or affected and no home-based care support services are in place", but the implications of these findings are not incorporated among project design issues. IFAD, 2000a, Appendix 1, p. 28.

87/IFAD, 2000a.

88/Sometimes appraisal reports may have changed considerably from the original formulation reports and some of the technical components may have been watered down. Checks and balances need to be put in place to ensure that HIV/AIDS initiatives are not watered down.

89/IFAD, 2000b, p. xi.

90/ Ibid.

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