1999 Malawi: Mid-Term Review of the UNICEF HIV/AIDS Programme, UNICEF Malawi
Author: Prebble, E. A.
UNICEF's assistance in the field of HIV/AIDS falls within the overall Master Plan of Operations for 1997-2001. Total UNICEF assistance for this period is planned to total US$48,000,000 (US$14,750,000 from general resources and US$33,250,000 from Supplementary Funds). UNICEF aims to achieve, through this programme, strengthened ability of men, women and families to provide improved care for children, and reduce the personal and social impact of HIV/AIDS on children and women.
Purpose / Objective
This impact study of the UNICEF HIV/AIDS programme is part of a series of background exercises, which will inform the Mid-Term Review of the UNICEF Malawi 1997-2001 Country Programme and make recommendations for steps to prepare for the next five-year Country Programme. The objectives of this study are:
- to assess the relevance, cogency and effectiveness of Country Programme interventions in the area of HIV/AIDS in connection with the national context, UNICEF policies and regional priorities
- through identification of lessons learned, best practices, effective strategies and priority gaps, make recommendations for strengthening the effectiveness and efficiency of UNICEF's Country Programme contribution to the fight against HIV/AIDS in Malawi for the remainder of the 1997-2001 Country Programme
- to make recommendations for improved future programming for the 2002-2006 Country Programme
A review of over 40 HIV/AIDS-related documents was conducted. Interviews were held with over 50 individuals that included: eleven staff from UNICEF, Lilongwe, and one from UNICEF Nairobi; 5 people from related UN agencies such as UNAID and UNDP; two World Bank officials; government staff from various departments and ministries; local NGO workers in Lilongwe, Chiradzulu and Blantyre.
Key Findings and Conclusions
In general, HIV/AIDS efforts which UNICEF has supported to date have been relevant, cogent, and effective, albeit insufficiently extensive or intensive. UNICEF has been a leader in HIV/AIDS prevention in Malawi, and according to one UN Representative, it was UNICEF who 'broke the silence' of HIV/AIDS within the UN system in Malawi.
UNICEF efforts have been consistent with Government of Malawi goals and objectives, and address, for the most part, the nine themes which have emerged from the Government's HIV/AIDS strategic planning process. Efforts have also been consistent with the objectives of UNICEF's own Master Plan of Operations (1997-2001); UNICEF's global Programme Priorities (1998-2000) and priorities of the UNICEF Eastern and Southern Africa Region (ESAR). Finally, UNICEF's programmes conform to the UN system goals in Malawi, as laid out in the 1998 United Nations Development Assistance Framework.
UNICEF has targeted youth in its HIV/AIDS work. While that is appropriate, the target should be more focused in future to concentrate on women of reproductive age, and specifically the girl child.
In the last UNICEF country programme, UNICEF Malawi had a full time staff member responsible for HIV/AIDS activities, closely tied to the health programme. In the current country programme, the decision was taken to abolish that post, and, instead, 'mainstream' HIV/AIDS into all of UNICEF's programme areas. This was apparently to ensure that each programme section of UNICEF integrated HIV/AIDS into their own section's programming. A focal point specifically for AIDS in the Workplace issues was named, but not for all HIV/AIDS activities and they are currently handled, with varying degrees of intensity, by staff in the following projects: Safe Motherhood, Family and Community Care, Youth Reproductive Health, Youth Participation, and Social Policy Development. The Programme Coordinator has informal responsibility for overseeing HIV/AID efforts, but is too over-committed with other responsibilities and programme obligations to give HIV/AIDS sufficient daily technical oversight and coordination.
Other shortcomings resulting from the absence of a full time staff member dedicated to HIV/AIDS include:
- diluted intensity of and accountability for UNICEF's overall HIV/AIDS efforts
- diminished visibility of UNICEF's efforts outside UNICEF
- the tendency toward vertical rather than integrated HIV/AIDS programming
- important opportunities for technical and programmatic convergence are missed, such as links between MTCT and safe motherhood programmes; between HIV/AIDS prevention programmes for youth and programmes of support for older orphans, etc.
- limited potential for consistent, in-depth coordination between UNICEF and National AIDS Control Programme (NACP)
- some HIV/AIDS programming opportunities get lost between UNICEF programme staff
- monitoring of orphan and youth support from UNICEF at district level and effective HIV/AIDS programme administration is less than optimal
Support for Orphan Care
UNICEF's approach to designing orphan support has been carefully considered and assistance has been thoughtfully delivered to ensure maximum impact and sustainability, and to avoid a welfare/charity approach. UNICEF's policy decision to not support orphanages is appropriate, and UNICEF support for orphans does not discriminate between HIV/AIDS orphans and children orphaned from other causes.
Highlights of particularly effective programme attributes in the orphan care sector include:
- establishment of community support groups and skills training
- support to guardians which both encourages community members to care for orphans and enhances orphans' welfare.
- income-generating activities for orphans which helps keep them in their villages (avoiding the migration to urban streets phenomenon)
- systematic registration and home assessments of orphans at community level to ensure comprehensive coverage of services
- provision of seeds and fertilizer to increase food security at community level and to help meet nutrition needs of orphans
- advocacy and information (IEC) to share best practices
- reviews of laws affecting orphans
UNICEF's (and Government's) ability to ensure careful administration and monitoring of orphan assistance at district level has been compromised by having only one staff member in UNICEF who deals with orphan issues and hence cannot travel extensively to the 26 districts.
Prevention of Mother-to-Child Transmission (MTCT)
UNICEF's efforts at sensitization about MTCT have somewhat lacked credibility, however, because UNICEF has not been able to articulate a clear set of interventions to prevent MTCT which are safe, affordable, sustainable, and appropriate in the context of Malawi. Many of UNICEF's partners mistakenly believe that MTCT is synonymous with provision of short-course Zidovudine (AZT), and naturally have concerns about budget and other implications. Lack of UNICEF providing a clear articulation of a MTCT strategy is no doubt at least partially responsible for UNICEF's observation that some of its government partners lack commitment in this area. In some ways, UNICEF's strongly advocating MTCT (in the absence of a clear strategy for action) may even have deflected attention from the primary goal of preventing women of reproductive age from becoming HIV-infected themselves.
UNICEF Malawi played an important role in supporting HIV/AIDS-related youth programmes when they were out of fashion for political and historic reasons in the early post-Banda years. Support has been given through UNICEF Malawi's Reproductive Health and Youth Participation Projects. They have attempted to serve both in-school and out-of-school youth.
UNICEF's youth-targeted work has been well-intended and well-managed, but the dramatic gap (among Malawi's youth) between knowledge about HIV/AIDS (which is high) and achievement of demonstrable sexual behavior change (which is low) is disappointing. IEC messages have been rather conventional and conservative. Messages and strategies which UNICEF supports need to be much more forceful, more provocative, more innovative and more interactive.
While much is known about youth's knowledge about HIV/AIDS and some things are known about patterns of sexual activity, little appears to be understood about the determinants of youth's sexual behavior and decision-making. Targeted behavioral research relying on focus group methodology would be helpful to guide programming in future.
Given the girl child's special vulnerability to HIV infection through initiation rites, consensual sexual behavior and sexual exploitation, special efforts need to be addressed to girls. It was noted that the vast majority of staff of both the Government's National Youth Council and youth section of the Ministry of Women, Youth, and Community Services are men, who may be ill-prepared to deal with needs of the girl child.
AIDS in the Workplace
UNICEF Malawi has taken a number of steps to address problems of AIDS in the workplace, and to ensure that UNICEF is helping prevent HIV among its own staff. Examples of activities undertaken include:
- improved management of illness in the workplace
- HIV/AIDS awareness seminars for staff and their families
- information, education and communication
- ensuring availability of treatment at the UN clinic
- funeral bereavement support
Five general guidelines are offered for UNICEF's planning of assistance for 1999-2001, specifically related to programming HIV/AIDS prevention:
1. Capitalize on UNICEF's comparative advantages, which include advocacy skills; a multi-sectoral approach to programming for youth; long-standing contacts in relevant ministries; experience with improving children's rights, etc.
2. Carefully analyze, and discuss with the NACP, the forthcoming National Strategic Framework, which will be the major outcome of the ongoing 18-month Strategic Planning Process. This process was designed to strengthen the capacity of communities to discuss and effectively respond to the epidemic. The process is expected to be completed before end-1999, and will offer UNICEF, and other donors, suggestions for programme support.
3. Build flexibility into UNICEF's HIV/AIDS programming because:
- the epidemiology of HIV/AIDS in Malawi may change (in terms of age groups most at risk, ratios of male/female infections, etc.), and programmes need to respond continually to new risk groups, new risk factors, etc.
- over the next few years, new and affordable strategies may become available to offer palliative care for PWAs, to prevent MTCT, etc.
- government policies and programmes may change
4. Put greater focus on meeting the HIV/AIDS-related needs of the girl child, including addressing girls' socialization regarding sexual behavior; cultural practices such as initiation ceremonies; etc. Seek new entry points for girls HIV/AIDS prevention education, including, for example, the USAID-funded Girls' Attainment of Basic Literacy and Education (GABLE) project.
5. Make the programmes which UNICEF supports bolder, more visible, more creative, and more provocative.
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