Built Environment Support Group

WORKING ON THE FRONT LINE

An Assessment of the Policy Context and Responses of AIDS Housing and Related Service Providers in the Durban Metropolitan Area

Janelle Wright

Built Environment Support Group

Tel: (031) 260 2267

Fax: (031) 260 2633

July 2001

aCKNOWLEDGEMENTS

The production of this report forms part of a wider programme of work undertaken by the Built Environment Support Group (BESG), addressing the impact of AIDS on the provision of adequate shelter and the housing environments of communities in KwaZulu Natal. With other affiliates of the Urban Sector Network (USN) BESG has participated in a two-year programme of policy development, research, networking and evaluating and developing models for the provision of appropriate shelter and living environments for individuals and communities impacted by the AIDS epidemic. We gratefully acknowledge the financial support of USAID who have funded the overall USN programme.

This report was researched and written by Janelle Wright during a period as a visiting research fellow with BESG. Our thanks go to Janelle and to her sponsors, the Henry R. Labouissee Fellowship for Development Studies at Woodrow Wilson School of Government, Princeton University, USA.

The production of this report was also made possible by the ongoing support BESG enjoys from its core funding partners, the European Union and EED (formerly known as EZE).

BESG 2001

Reproduction or use of all or part of this publication will acknowledge the author, Janelle Wright, and BESG. Reproduction or use of this material for gain may only take place with the written permission of BESG.

Built Environment Support Group

July 2001

1BUILT ENVIRONMENT SUPPORT GROUP

Background

BUILDING A COMPREHENSIVE AIDS PROGRAM

In December 2000, the Built Environment Support Group (BESG) initiated a scoping exercise to identify the range of housing and related resources for persons affected by AIDS. Following preliminary discussions with AIDS education and outreach organizations, the project was refined to examine the impact of the current financial and regulatory environment on the capacity of AIDS housing and social service providers. It was envisioned as part of a broader process to formulate a comprehensive and integrative AIDS housing program for BESG.

The objectives of the project were outlined as follows:

Research: Identify the range of housing and related resources for those affected and infected. Questions guiding this process include: What is the impact of AIDS on a household’s ability to obtain and maintain accommodation? What institutional and community supports are currently available for households whose insecurity and vulnerability increases as a result of AIDS? How do community groups and local institutions respond to increasing demands for their services?

Development: Utilize the information obtained from the research process to inform BESG’s interventions in the field of supportive housing and guide the process for developing a cohesive AIDS housing strategy.

CapacityBuilding: Engage with specialists in the AIDS arena as a means of strengthening institutional partnerships and exchange across a variety of sectors.

BESG believes that mitigating the impact of the epidemic on households and local communities should be a core principle of its overall strategy. This scoping exercise is one step toward achieving that broad objective.

METHODOLOGY

The contents of this report are based on a series of discussions and qualitative interviews with HIV/AIDS service providers throughout the Durban Metropolitan Area (DMA), site visits, and an assessment of relevant policy and legislation. The research was divided into the following two phases:

Phase I entailed a review of relevant literature on the socio-economic effects of the epidemic in South Africa and an overview of government policy at the national and provincial levels. Emphasis was placed on legislation from the Departments of Housing and Social Development.

Phase II was comprised of informal discussions and interviews with key informants, staff members of AIDS service organizations, and representatives of local communities. Organizations and individuals were identified using a snowball sampling strategy that commenced by compiling a list of organizations found in AIDS service directories. A series of site visits were also included in this phase. A total of 13 organizations and programs were visited; 28 individuals were interviewed. Nina Saunders provided assistance during the interviewing process.

The analysis of local and community-accessible resources was broadly divided into three phases: provision – what resources are being provided and how are they provided? Utilization – who are the actual beneficiaries of this provision? Assessment – how does provision of services influence the level of need “on the ground”, and what public sector interventions are required to improve the positive impacts of these initiatives?

There were several limitations to this approach. First, as a result of the methodology employed, the interviews were primarily conducted with older, established institutions. Consequently, this scan only provides a limited glimpse of the range of informal, community supports available. Second, a high value was placed on capturing the voices and concerns of affected and infected persons. However, regard for confidentiality limited the extent to which these individuals could be personally consulted. Many of their concerns are represented indirectly through the local institutions that support them and community volunteers that attend to their needs. Finally, this report does not provide a comprehensive review of all policy for affected and infected persons. Emphasis has been placed on an assessment of legislation from the Departments of Housing and Social Development, in an effort to determine what provisions are available for directly and indirectly supporting the economic and social needs of these individuals.

PROBLEM STATEMENT

AIDS has emerged as one of KwaZulu Natal’s most formidable development challenges, with consequences extending far beyond the health sector. Since 1990, the national Department of Health has tracked the progression of the HIV virus through anonymous testing of women attending antenatal clinics. Their estimates have consistently identified KwaZulu Natal as the province with the highest HIV prevalence rates, increasing from 19.90% in 1996, to 26.92% in 1997, up to 32.5% in 1999 (Depart of Health). These figures have translated into conservative estimates of approximately 2.9 million infected persons and 100,000 child orphans (HEARD 2000).

These aggregate figures prove quite useful in provincial comparisons, but provide little insight into the effects of HIV/AIDS at the local level. It is increasingly apparent that the epidemic has taken a toll on the economic and social stability of communities and households. This finding becomes even more significant if the prevalence of the disease is assessed in light of the incidence, depth, and severity of poverty throughout the region. Over 36% of households in KwaZulu Natal live in poverty (Heard, 2000). When AIDS strikes these vulnerable households, the resources of its members erode quickly and the household becomes more susceptible to further economic and social insecurity. Thus, as Jill Donahue demonstrates in her discussion paper on Community-Based Economic Support for Households Affected by HIV/AIDS the disease can catalyze a shift from relative poverty to absolute destitution. (Donahue, 1998)

Table 2: Basic Demographic Indicators for KwaZulu Natal
Population (1996) / 8 471 021 persons
Per Capita Income (1993) / R 6 157
Human Development Index (1994) / 0.58
Poverty Rate (2000) / 304 959 households
Life Expectancy (1996) / 61.7 years
Unemployment (1995) / 32.2% of population
Disabled (1995) / 6.0% of population
HIV Positive Adults (2001) / 3 870 873 persons
HIV Positive Children (2001) / 200 597 children
Source: Statistics SA, HEARD

Since the socio-economic impacts of the epidemic are felt at the micro-level first (in terms of changes in household consumption/expenditure patterns and the channeling of female labor from productive activities to reproductive care), recent studies suggest that AIDS is exacerbating levels of shelterpoverty. Poor households stricken with the disease are less able to pay for the costs associated with maintaining their housing units. Large numbers of orphans are left without shelter or basic needs provisions. And infection rates among homeless populations appear to be increasing, because lack of adequate shelter constrains their ability to participate in medical treatment programs and access other vital health resources. These combined factors are elevating the demand for affordable units, while reducing the financial and human resources that households can contribute towards obtaining them.

The current shifts in policy toward individual self-sufficiency and community self-reliance suggest that community organizations and local institutions assume much of the responsibility for mitigating the effects of AIDS on the “shelter poor”. Since these groups offer potentially promising approaches to addressing the needs of children and families, their activities are generating significant interest among donors, policy makers, and local government. However, little information is known about how these entities cope with increasing demands for their services and fluctuations in public sector support. Whether or not local institutions and their community partners have the capacity to transform pilots into systematic reform efforts and templates for development has yet to be determined.

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AIDS HOUSING CRISIS

MULTIDIMENSIONALITY OF POVERTY

BROADENING OUR UNDERSTANDING

Over the past decade, assessments of the extent and nature of poverty have shifted emphasis away from income and consumption-based measures in favor of composite indices of human development. Income and consumption-based measures are typically referred to as ‘objective’ social indicators, derived using income, expenditure patterns, and levels of consumption for food, housing, and other vital needs (May, 2000). These two approaches are widely employed in basic analysis of the incidence and severity of poverty, but have been severely scrutinized for conceptual and methodological flaws. Critics (Bernstein, 1992) assert that they promote a narrow conception of basic needs and prove difficult, if not impossible, to measure when household data is aggregated. Challenges such as these have fuelled efforts to develop broader conceptions of poverty and deprivation, beyond the criteria of mere physical survival (May, 2000).

The Human Development Index (HDI), a composite measure of life expectancy, adult literacy, and real per capita income, is an example of one such approach. Adopted by the United Nations Development Program, HDI aims to differentiate between poverty as a lack of assets, income, and physical resources; deprivation in regard to isolation and powerlessness; and vulnerability, as a reflection of insecurity and limited resilience against shocks. Noting that: ‘The quality of people’s lives can be poor even in the midst of plenty’ (Human Development Report 1996), these dimensions of poverty underscore the importance of integrating both income and non-income factors into our analysis.

In regard to housing and urban development, Stone (1993) developed a useful model for understanding how a household’s efforts to maintain adequate, secure accommodation influence their consumption and expenditure patterns for non-housing goods. His shelter povertyapproach is premised on the need to develop a more appropriate measure of basic needs and housing affordability. In contrast to measures of income-poverty, a household can be considered among the “shelter poor” if they

1)Lack accommodation;

2)Are at risk of losing their unit in which they currently reside; and/or

3)Occupy their present unit, but reserve so much of their income for housing-related costs that they are unable to meet other basic needs at some minimum level of adequacy.

Conceptually, this approach represents a step forward in understanding deprivation and vulnerability in relation to other key dimensions of welfare.

AIDS & SHELTER POVERTY

SUMMARY OF RESIDENTIAL NEEDS

Discussions with community volunteers, affected and infected persons, and representatives of various AIDS service organizations suggest that the impact of HIV/AIDS on the shelter poor has been severe. No data is available to determine the degree to which Aids preys on these households. However, the voices of those involved in the field elucidate the challenges affected and infected persons encounter in efforts to maintain their homes.

 Multiple Needs of Clientele. The most prevalent theme from the research is that AIDS housing and social service providers need to cater to a variety of residential and non-residential needs of their clientele. For example, children need emotional support, guidance, food, shelter, and clothing. They need to maintain familial ties, obtain decent education, and socialize. The multiplicity of needs necessitates that service providers develop creative and flexible approaches to service delivery, and are willing to form partnerships with organizations that demonstrate expertise in areas in which they have little experience.

 Shifting Demands. HIV/AIDS is shifting the demand for housing by altering the demographic profile of the population, family structure, and household functioning. A greater diversity of tenure arrangements, emergency bed space, and adaptations to existing units are needed to accommodate growing numbers of the disabled, indigent persons, and child-headed households, among others.

Greater diversity of tenure

The limited availability of tenure systems other than full homeownership presents a significant challenge for infected persons, as they often transition through cycles of relative physical wellbeing to severe medical crisis and indigence. The transitional facilities and short-term accommodation necessary to assist these persons are either non-existent in some areas or severely overcrowded in others.

Emergency bed space

The need for emergency bed space and placement assistance is tremendous, particular for homeless women and children. Traditionally, extended families and community support networks have been able to absorb homeless persons into their own families. However, as more households are affected, the extent to which these social support networks will be able to assist those outside their own families will be extremely limited.

Adaptations to existing units

Reliance on extended family structures and other community-support systems has resulted in severe overcrowding, which can often lead to hygiene and sanitation problems. Many existing units are in need of expansions to accommodate larger families, upgrades to dilapidated sections, and/or adaptations of current facilities to assist caregivers in providing for person with physical impairments.

 Expanded Range of Support Services. There is an increasing need to expand the range of supportive services that accompany the various residential models. Bereavement counseling, education, emotional support, and medical services for both children and adults are among the most common support services offered. Only recently, has greater attention been given to the viability of matching urban agriculture, income-generating projects, and social insurances schemes with supportive housing models. As a result, most of these initiatives, which offer the possibility of creating security and income for indigent families, remain small pilot projects.

 Barriers to Accessing Support. The lack of access to accurate information about the housing and support services available impedes infected and affected persons from receiving assistance. Affected and infected persons have only limited knowledge of hospices, places of safety, and other accommodation currently operating. An appropriate mechanism for disseminating this information is needed, given that rights of admission and requirements for use vary from facility to facility.

Additionally, the stigma attached to health care facilities, hospices, and homes for the indigent discourages many from utilizing their services. Much of the apprehension results from these institutions being perceived as places where an individual can “die with comfort and dignity,” rather than a temporary accommodation where they can rejuvenate themselves and subsequently reintegrate into their community.

 Legal & Regulatory Frameworks. Legal and regulatory frameworks are not currently in place to ensure the transfer of property and material assets from deceased parents to their dependants. Home-care volunteers express concern over how to ensure and enforce the respective rights of extended families and orphaned children. Many encounter instances in which relatives “usurp” the property and material assets of children and youth whose parents are deceased.

Additional provisions are needed to assist increasing numbers of child-headed households. Home-care volunteers also express concern over the lack of protocols to assist child-headed households. They recommend that procedures such as waiving school fees for orphaned children and instituting an extended grace period for the payment of rates be systematized.

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POLICY ENVIRONMENT

The limitations of existing service delivery systems have led KwaZulu Natal’s Department of Housing and the national and provincial Departments of Social Development to formulate responses to the HIV/AIDS epidemic. Though widely varied, these policies share some basic premises:

Support should be targeted to children, because of their vulnerability to shocks and limited resiliency to recover from changes in the socio-economic conditions of poor households

Responsibility for the development, implementation, and operation of programs and support services should reside at the community or neighborhood level

Partnerships are critical to the efficient and effective use of limited resources and skills, as well as addressing the multiple needs of those affected.

This section provides an overview of the financial, legislative, and programmatic measures these departments have taken to mitigate the effects of the epidemic. Though tremendous strides have been made, there is little co-ordination between the Departments of Housing and Social Development. Moreover, [continue…] Concern from DoH are: pace at which change happens + insufficient funding + limited administrative capacity

Built Environment Support Group

aCKNOWLEDGEMENTS

table of contents

PAGE

1BACKGROUND

Background

BUILDING A COMPREHENSIVE AIDS PROGRAM

METHODOLOGY

PROBLEM STATEMENT

AIDS HOUSING CRISIS

MULTIDIMENSIONALITY OF POVERTY

BROADENING OUR UNDERSTANDING

AIDS & SHELTER POVERTY

SUMMARY OF RESIDENTIAL NEEDS

POLICY ENVIRONMENT

The limitations of existing service delivery systems have led KwaZulu Natal’s Department of Housing and the national and provincial Departments of Social Development to formulate responses to the HIV/AIDS epidemic. Though widely varied, these policies share some basic premises: