STRENGTHENING COMMUNITY CAPACITY TO HIV/AIDS IN WEST AND CENTRAL AFRICA
Strengthening Community Response to HIV/AIDS
In West and Central Africa
A Capacity Building Approach
HIV/AIDS and Communities : a journey into change
A Partnership between
The Salvation Army enda tiers monde/ Santé HOPE worldwide
Health & HIV/AIDS Co-ordinator
April J. Foster
Regional Programme Co-ordinator
HIV/AIDS, Health & Development
The Salvation Army
Dr. Marc Aguirre
Abidjan, Cote d’Ivoire
The following document will describe the experience of a regional partnership for strengthening community responses to HIV/AIDS in Senegal, Cote d’Ivoire, Rwanda and Nigeria. This will include :
- A description of the process/methodology (Volume I)
- Facilitators Notes for the steps in the process (Volume I)
- Country profiles/experiences, including outcomes and
indicators (Volume II)
- Lessons Learned : successes and challenges (Volume II)
- Suggestions on the Way Forward (Volume II)
Over the past several years, the UNAIDS Inter-Country Team for West and Central Africa (ICTWCA), together with other partners such as the UNDP Regional Programme on HIV/AIDS and Development identified the need to strengthen community-based responses to HIV/AIDS in the West/Central Africa sub-region.
After several informal meetings between UNAIDS, The Salvation Army Regional Team, Enda Sante (Senegal), and others, a workshop for representatives of NGO’s/CBO’s and government programmes was held in Abidjan in March 1999. The objectives of this workshop were to share experiences from the field on community responses, to identify a process for developing a shared vision and ways of working with communities, and to document the approach and outcomes of this process.
One immediate outcome of this workshop, was an agreement between Enda Sante and The Salvation Army Regional Team to collaborate in a process of facilitation and documentation of strengthened community responses to HIV/AIDS in 4 pilot countries in West/Central Africa over a 2 year period.
Some of the concerns driving this collaborative response between Enda Sante and The Salvation Army included :
- The continued accelerating nature and effect of the HIV epidemic, that is still largely ‘unseen’ in many West/Central African countries, but is beginning to become more ‘visible’.
- The need to respond to this epidemic in ways that build capacity of communities to own and respond to the effects of HIV, and to sustain hope and change.
- The need to keep learning and applying skills in the context of the changing community realities (eg.psycho-social support to orphans and vulnerable children)
- The need for organisations working with HIV/AIDS in West/Central Africa and in East/Southern Africa to share experiences with each other, in a way that does not duplicate programme models, but shares ways of working and foundational principles that are transferable and effective.
The broad objectives of this collaborative process included :
- Strengthening the capacity of organisations to facilitate community responses to HIV/AIDS that integrate care with prevention, keeping in mind other priority concerns such as coping strategies, orphans and vulnerable children, health and development, etc.
- Sustaining local action by increasing the capacity to care, change and find hope within the community, and the transfer of lessons learned to other organisations
- Identifying and developing skills of a resource ‘pool’ of facilitators, who can give support to local action both at country and inter-country levels
- Reinforcing the capacity within the community to better understand the nature of the epidemic, to reflect and to initiate changes to respond effectively
- Skills building workshops in 4 pilot countries
- In-country follow-up/support visits (See Protocol in Appendix)
- Facilitated community conversations/activities in 3 communities per country
- Documentation (at regional, local and community levels)
- Evaluation as an integrated, on-going part of the process
- Local Facilitators team reflections
In the face of a phenomenon so intricately linked into the fabric of a society and as personally and professionally threatening as the HIV epidemic, it may be that only programmes which penetrate the soul of a community, organization or nation will be effective(Campbell 97).
On the basis of their community-based experiences over the past decade, Enda Sante and The Salvation Army have developed a similar vision based on capacities within communities to care, change and sustain hope in the midst of the HIV/AIDS epidemic. Responses to the epidemic need to be based in the reality of existing social dynamics/relationships and the concerns of local communities. The creation of ‘spaces’ of trust and mutual respect are critical, where genuine interaction can stimulate sustainable changes from within the community that are relevant to HIV/AIDS prevention, care and reducing the impact of the epidemic. This process is often accelerated by a facilitation team approach (from within and/or outside the community), which works in respect and inclusion of all actors.
These practices have not generally been applied to the global or the national responses to the epidemic. Yet there may be a way to touch the soul of a community or organization, a way of catalyzing transformation from the inside out. These practices form the basis of our capacity building approach.
A capacity building approach focuses on people and their interactions, on their capacities and resources. The essence is the way in which all those concerned work together. It recognizes that people have capacities and knowledge, and validates these and builds on and strenghens them in their groups. It also aknowledges that people can hold false beliefs, be misinformed or act in bad faith. It is essentially an interactive process of observing, reflecting, questionning and making decisions for change together.
A capacity building approach starts from where people are, their perspectives of the situation and their interest in change. Through these processes of inclusive interaction, collective or social learning occurs, power relations shift, changes are initiated and ownership and responsability for change is strengthened, and local capacities and resouces are mobilized. These latter include material resources, social systems, time, social capital, skills, knowledge, values, tradition, etc…
Capacity building and a contributing facilitation team approach must be experienced and practised to be grasped. The grasping is an ongoing experience.
WAYS OF WORKING
The following ways of working were fundamental to the approach :
- Sensitivity to local, family and community experience – working by invitation and commitment, not imposition
- Facilitation rather than intervention of ‘experts’
- Participatory approaches with space for listening, inclusion, agreements, expressions of concerns, etc.
- Team formation at organisational and community level for implementation
- Respect of differences, mutual trust
- Strengthened community responses in 4 pilot locations (16 communities) in West/Central Africa
- A documented approach to strengthening community responses (including conceptual and methodological frameworks and facilitators notes)
- Documentation of community activities, outcomes and indicators
- An increased understanding of effective ways to respond to the changing nature of the epidemic at communty, national and regional levels
- The development of a regional ‘resource pool’ of facilitators with capacity and experience to implement as well as facilitate others
- The transfer of skills and experience/lessons learned with other communities and organizations
The HIV/AIDS pandemic has challenged the way individuals, families, communities and nations think about relationships, culture, faith, economics, and our future. Despite intensive efforts from governments, NGO’s and communities, the continued spread of the virus and its effects will be seen and felt for the forseeable future. The impact on development, the increasing disparity between people, and the impact on children are being increasingly felt in most countries in the Africa region. In the face of this epidemic, we are faced with questions about how to live together?, How to work together?, How to expend the resources available to us?, and how to move into the future together with hope?
Belief in the capacity of communities to care, change, name and document their change, share and transfer their experience with others and sustain hope in the midst of the HIV/AIDS pandemic is foundational to an expanded response.
The ways that organizations work with communities in this process, can either strengthen this capacity or inhibit it from reaching its full potential.
The collaborative process between The Salvation Army, Enda Sante, HOPE worldwide and UNAIDS has demonstrated that working in participatory ways through a community counseling methodology facilitates community determined and sustained change and transfer, and has contributed to an expanded response to HIV/AIDS in the 4 participating countries of Senegal, Nigeria, Rwanda and Cote d’Ivoire.
Across all four countries, the following were major LESSONS LEARNED and reinforced:
- A facilitation team that works by invitation, and in participatory ways is a critical factor in stimulating local, national and regional capacity development to respond to HIV/AIDS
- Communities have capacity to reflect on their concerns related to HIV/AIDS, to make decisions/changes in the areas of care and prevention, to name indicators of these changes and document their response, and to transfer experience and skills to others
- Where responses have existed before, the approach can strengthen and ‘value add’ to improve ways of working and help to achieve desired outcomes of community determined change, care, prevention and transfer (eg HOPE worldwide – Cote d’ Ivoire and Nigeria, World Relief – Rwanda)
- Where responses have not existed before (eg Salvation Army Rwanda), the approach builds on existing community capacity, and results in qualitative, community owned initiatives, and quantitative transfer from community to community
- The approach is regenerative, in that it multiples itself in terms of community capacity, teams, facilitators, etc. For example, from the initial group of facilitators trained in each country, other community members and organizations have become involved.
- Partnerships that have their basis in supporting local action strengthen the individuals participating as well as the organizations which they represent (eg Enda Sante and Salvation Army have been strengthened by sharing vision, ways of working, and methodologies that have been grounded in community experience
- The approach of strengthening community capacity yields many outcomes, for comparatively minimal financial input
- During the pilot programme, approx. 100 community facilitators were trained in 4 countries. The development of a regional resource pool of facilitators with experience and skill in this approach is another outcome of the process. Three facilitators joined the Enda Sante/Salvation Team for support to other countries (Senegalese to Nigeria, Cote d’Ivoire to Senegal and Cote d’Ivoire to Nigeria) An additional 7 facilitators were seen to have capacity to work cross- boarder in facilitating this process with others. This group of facilitators is multi-organisational in nature, and represents a valuable resource in the region for strengthening and expanding responses to HIV/AIDS.
- In addition to HIV/AIDS, this approach can be used with wider and inter-related issues, such as migration, orphans and vulnerable children, sanitation, and other development concerns.
SUGGESTED WAYS FORWARD
There is a strong belief and commitment to the validity of this approach among the participating organizations in the collaborative partnership. The following are suggested ways forward to build on this existing experience, and expand its impact in the region:
- Expansion of the process to other country locations, particularly to countries where the response to HIV/AIDS needs strengthening
- Utilisation of the regional resource pool of facilitators (10+) by organizations such as UNAIDS, UNDP and others, for facilitation in areas of HIV/AIDS, migration, health and development
- The current experience should be as widely publicized as possible, as a UNAIDS Best Practice Case Studay, at regional and international conferences, in the media, etc.
- Resources should be allocated to continue this process, and should be seen as an investment in long-term, sustained community responses to HIV/AIDS
C O N T E N T S
COTE d’ IVOIRE
APPENDIX : Outcomes and Indicators
Rwanda Country Profile Chart
Cote d’Ivoire Country Profile Chart
Senegal Country Profile Chart
Nigeria Country Profile Chart
HIV information among antenatal clinic attendees is available from Rwanda since the late 1980’s. In Kigali, the major urban area, 32 percent of antenatal clinic attendees tested in 1988 were HIV+. HIV prevalence has ranged between 25 and 33 percent among antenatal clinic attendees in Kigali through 1995. In 1997, HIV prevalence ranged from 10 to 28 percent among antenatal clinic women tested at two sites. Peak HIV prevalence of over 35 percent was seen among 20-24 year old antenatal clinic attendees in both 1989 and 1992-3.
Outside of Kigali, HIV prevalence among antenatal clinic attendees ranged from 10 to 8 percent from 1989-90 to 1997. In 1996, HIV prevalence among antenatal attendees tested in 6 sites outside of Kigali ranged from 4 to 17 percent. During 2000, peak prevalence was seen among the 20-29 year old antenatal attendees.
Information on HIV prevalence among male STD clinic patients is available from Kigali since 1986. HIV prevalence reached 55 percent among male STD clinic patients tested in 1988-1990. In 1996, 29 percent of STD clinic patients tested in Kigali and 55 percent of patients in Biryogo were HIV positive. Among female STD clinic patients tested, HIV prevalence ranged from 69 to 77 percent between 1986 and 1991.
Estimated Number of adults and children living with HIV/AIDS, end of 1999
Adults and children400,000
Children (0-14) 22,000
Estimated number of deaths due to AIDS
Deaths in 1999 40,000
Estimated number of orphans
Current living orphans172398
(WHO Epidemiological Fact Sheet – 2000 Update)
Rwanda, a country that heavily depends on agriculture (more than 90% of the population is engaged in agricultural-related activities) is definately bound to feel the effects of the epidemic as more and more of its productive age group become infected and affected by the HIV/AIDS virus. HIV/AIDS is often excluded from insurance schemes, leaving low income sero-positive patients financially strained, and exposed to other related problems. A USAID funded survey found that half of the sero-positive patients interviewed were widowed, and that they use up to 10 times more basic healthcare services than the general population.
During the pilot programme, 30 facilitators were trained from two organisations :
The Salvation Army (Kayenzi) The Salvation Army first entered Rwanda shortly after the genocide in 1994, with relief work in the Kayenzi commune. Since that time, numerous development programmes have been started (feeding, housing and agriculture), working together with community leadership and government. The Salvation Army now has several church centres, from which on-going community development work, and a response to HIV/AIDS take place.
World Relief – RwandaWorld Relief is a well known faith-based NGO, that works primarily with relief and development activies in Rwanda, through local church networks. Activities include materials production, micro-credit schemes, and an HIV/AIDS programme with pastors of churches throughout Rwanda.
The initial skills building workshop for the facilitation team, was followed by two follow-up/support visits.
The Salvation Army team of facilitators returned to Kayenzi community following the training, and divided themselves into 4 groups, to begin discussions with men, women, youth and children. Over the initial 3 month period prior to the first follow-up visit, facilitated discussions with each of these groups took place in the local Salvation Army church building These discussions were primarily with church members at this stage. Local authority permission is needed to hold any public meetings, and initially this permission was not given to the Salvation Army facilitators. During the first 3 months, news of what was happening spread to the local leaders, who made enquiries, observed for themselves, and later gave their support to the team to move throughout the community, facilitating discussions and other activities related to HIV/AIDS care and prevention.
The team used a wide variety of the skills and tools which they had learned in the training such as: transect walks, strategic questions, story-telling, social capital and HIV/AIDS and drama/role plays/songs.
The recent history of Rwanda, created unique challenges in working with the community.
Following the genocide, the pattern of relief work that categorized most NGO’s was based on a necessary provision of immediate assistance to meet a variety of needs. This type of relationship between communities and organizations like The Salvation Army and World
Relief is being shifted through a facilitated process, using locally trained facilitators and counselors, and drawing on community strengths and resources.
Following the counseling process, the facilitators felt they had built a good relationship with community members, and also started to identify and explore community concerns.
During a 6 month period, the initial work in Kayenzi community was transferred to over 6 other areas, through specific requests of these communities who had heard what was happening in Kayenzi.
Due to the increased openness of community members to talk about HIV/AIDS, and the care and concern of the team, people living with HIV/AIDS began to make themselves known to the facilitation team. At the present time, over 50 people living with HIV have identified themselves to the team.