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Orphans and Vulnerable Children in sub-Saharan Africa. Tonya Renee Thurman, MPH, PhD Social Impact of AIDS Class lecture, April 11 th 2008. Overview. Who are OVC? Terminology Definitions Prevalence & estimations Evidence of “vulnerability” Considerations for programming Targeting OVC

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orphans and vulnerable children in sub saharan africa

Orphans and Vulnerable Children in sub-Saharan Africa

Tonya Renee Thurman, MPH, PhD

Social Impact of AIDS

Class lecture, April 11th 2008


Who are OVC?

  • Terminology
  • Definitions
  • Prevalence & estimations
  • Evidence of “vulnerability”

Considerations for programming

  • Targeting OVC
  • Key Strategies and Considerations
  • What works?
  • Way Forward
  • AIDS Orphans
  • CABA (Children Affected by AIDS)
  • Orphans & Vulnerable Children (OVC)
who are vc
Who are VC?

The definition of “Vulnerable children” influenced by donor priorities and often tend to refer to children affected by HIV and AIDS, such as:

  • Children living with caregivers who are chronically ill, possibly due to HIV/AIDS;
  • Children who are HIV positive
  • Children living with their parents in fostering households, which may have recently taken in an orphaned child
definition of vc an example from the field
Definition of VC An example from the field
  • USAID South Africa defines the “V” as those who are more vulnerable because of any or all of the following factors that result from HIV and AIDS :
    • Is HIV-positive
    • Lives without adequate adult support (e.g., in a household with chronically ill parents, a household that has experienced a recent death from chronic illness, a household headed by a grandparent, and/or a household headed by a child);
    • Lives outside of family care (e.g., in residential care or on the streets); or
    • Is marginalized, stigmatized, or discriminated against.
definition of vc an example from the field1
Definition of VC An example from the field

USAID South Africa goes on to say:

  • “This operational definition identifies those who are potentially eligible for services, but does not identify those most in need of services. To inform programmatic decisions, each community and program will need to prioritize those children most vulnerable and in need of further care.”
  • More flexibility to allow OVC to include children whose parents are alive but who live with relatives or non-relatives under strained capacity;
  • Thus, the V becomes a very lumpy and catch-all term
orphan definition
Orphan Definition
  • American Heritage Dictionary defines an orphan as “a child whose parents are dead.”
  • Internationally recognized definition of an orphan is: “a child age 0-17 years old who has lost one or both parents”
    • Single orphan – a child who has lost one parent.
    • Double orphan – a child who has lost both parents.
    • Maternal orphan – a child whose mother has died

(includes double orphans).

    • Paternal orphan – a child whose father has died

(includes double orphans).

prevalence of orphans
Prevalence of Orphans

~ Hordes of Orphans ~

In developing countries:

  • 132.7 million orphans across Asia, Latin America and sub-Saharan Africa (SSA)

In sub-Saharan Africa:

  • 48.3 million orphans
    • 12% of all children age 0-17
  • 9.1 million are “double orphans”

(Unicef, 2005 estimates)

cause of orphanhood
Cause of Orphanhood

Over 12 million children in SAA have been orphaned by AIDS

Source: UNAIDS and UNICEF Estimates, 2006

percent orphaned by aids and other causes
Percent Orphaned by AIDS and Other Causes

Source: UNAIDS and UNICEF Estimates, 2006

orphans became shorthand for the cumulative community impact of aids
“Orphans became “shorthand” for the cumulative community impact of AIDS

Foster 2006


In many African countries,

even if new infections leveled by the year 2000...

Infection rates will remain high

through at least 2010

Deaths will not level until 2020

The proportion of children orphaned will be

unusually high through at least2030

estimating numbers of o vc
Estimating numbers of OVC
  • Number of Orphans (maternal, paternal and double) has been more accurate and more readily available.
  • Rely on demographic & epidemiological data
  • Sources include: Demographic Health Survey, Multiple Indicator Cluster Surveys, Census Data, Birth/Death Registration
estimating numbers of o vc1
Estimating numbers of OVC

Some Basics:

  • Different methodologies for calculating estimates and projections
  • Factors considered include:
    • HIV prevalence
    • Adult Mortality
    • Fertility rates
    • Size of child population
    • Marriage and reproductive patterns
    • Vertical transmission rates
  • Total orphans = maternal orphans + paternal orphans - double orphans.

Details on modeling and projections can be found in UNICEF, 2006 Annex & work by Grassly et al.

estimating numbers of o v c
Estimating numbers of OVC
  • Vulnerability concerning HIV/AIDS
    • In Zambia, for example, 11.8 per cent of children were vulnerable in 2005:
      • They either lived in a household with a chronically ill adult, had a chronically ill parent living outside the household, or had experienced an adult death in their household in the last year (UNICEF 2006)
  • Child-headed households
    • Large demographic surveys do not show any substantive numbers of CHH.
estimating numbers of o v c1
Estimating numbers of OVC
  • But, how to estimate or measure the number of “vulnerable” beyond this has been more problematic.
  • Not all definitions can be measured, so USAID has started to look at definitions that can be supported by data.
current efforts towards total numbers of ovc
Current Efforts towards total numbers of OVC

OVC Estimates: Model 1

(LaTour, USAID Office of the Global AIDS Coordinator, NIH/USAID OVC Mtg, 2008)

why do we care
Why do we care?
  • Larger numbers are good for advocacy and bringing attention to the need for services and resources.
  • However, the larger number reduces coverage rates significantly. This could have negative consequences at a policy level.
  • All numbers have different implications for planning appropriate programs.
global estimates considerations
Global estimates: Considerations

Absolute numbers vs Percentages

global estimates considerations1
Global estimates: Considerations
  • How orphan and/or vulnerable is defined
    • What type of “O?” Who are the “V?” Is it just “O” or OVC?
  • Age of population
    • Almost half of all orphans and two thirds of double orphans are adolescents ages 12–17 (Unicef 2006 ).
    • Some profiles are limited to certain age groups (e.g., 0-14 yrs)
global estimates considerations2
Global estimates: Considerations
  • Rarely provide gender profile
    • Global statistics often not disaggregated by gender
  • Data source
    • Availability, accuracy, representativeness
    • Different data, methods, and assumptions used by different organizations
    • Are we capturing the most vulnerable? (e.g., street kids, those in institutions, migrant & refugee children, CHH missed in household based surveys)
evidence of vulnerability
Images are often negative

Pull at the heartstrings

Picture of sadness –only smile when…..

Evidence of “vulnerability”
  • Peter Ouma, an orphan in Nyalenda slum, Kisumu, Kenya, cries after falling, 2006. Photo by Paul Di Stephano, courtesy of Photoshare.

Problems commonly associated w/ OVC


Food intake Malnutrition

Health care Ill health

Schooling Workload, labour

Safety, stability Migration, distress

Nurture Exploitation, abuse

Identity, security Homelessness

Love & affection Abandonment, rejection

Adjustment Maladjustment

Protection Vulnerability to infection

Inclusion Exclusion

(Richter, 2006)

evidence of vulnerability1
Evidence of vulnerability
  • Most available data concerns orphans
  • Little research as to the vulnerability of the other types of aids affected “V” group
  • Most data concerning issues facing children living with an HIV parent is from low prevalence countries, and even then:

“Current evidence base is too geographically limited with insufficient evidence of the underlying causal relationships to allow for generalizable conclusions about the situation of children affected by HIV/AIDS” (Lynne Franco, NIH/USAID OVC Mtg, 2008)

evidence of vulnerability o v c
Evidence of Vulnerability: OVC

Issues facing children living with an ill caregiver

Psychosocial problems

  • Burden of taking care of family member
  • Watch parents suffer and die.
  • Worry about the future.
  • Fear they are infected
  • Depression, Anxiety (Stoppelbein, 2000)
  • Minimal parent-to-child discussion  worry in silence.
evidence of vulnerability o v c1
Evidence of Vulnerability: OVC

Issues facing children living with an ill caregiver


  • School withdrawal, poor attendance
    • Tanzania: Reduced hours in months previous to parent death in Tanzania (Ainsworth, Beegle, Koda2005)
    • Kenya: Maternal: 6.6 percentage point drop in attendance in 1-2 years before death (2/3 of total effect) in Kenya (Evans & Miguel 2007)
    • Kenya: Children in households with parents just starting ARV attend 10% fewer hours of school per week in [Treatment reduces that to 2%] (Zivin, Thirumurthy, & Goldstein 2007)

Other potential risks

  • Economic hardship
  • Increased risk of HIV infection?
evidence of vulnerability o v c2
Evidence of Vulnerability: OVC

Impact of Disclosure

  • Remains an empirical question
  • Likely related to treatment availability and child developmental stage

Children living with HIV

  • Little is known about adherence and illness management skills
  • Risk reduction will become important with sexual debut
evidence of vulnerability o vc
Evidence of vulnerability: OVC

With whom do orphans live?

  • Majority of orphans are living with surviving parent
    • Counters the widely held myths about orphaning in Africa
  • Many children now in permanent care of extended kin.
  • Children more in care of maternal kin
    • in paternal societies this can be associated with stigma, loss of property etc.
with whom do orphans live1
With whom do orphans live?


  • At least >127,000 in East Africa living in institutions (grossly underestimated)
    • In Zimbabwe:50% of those living in institutions have at least one parent alive
    • In Ghana: 80% in institutions have existing families.
    • In Swaziland: “Many” go home to family on weekends

(Greenberg, NIH/USAID OVC Mtg, 2008)

evidence of vulnerability o vc1
Evidence of vulnerability: OVC

Orphans and psychosocial issues

  • Consistently negative outcomes for internalizing symptoms (Sherr, in press)
  • Sibling separation, bereavement & loss of affection are sources of distress
  • Lack of standardized or consistent measurements
  • Little evidence of behavioral problems

Orphans and abuse

  • Principally anecdotal
evidence of vulnerability o vc2
Evidence of vulnerability: OVC

Orphans and education

  • 102 surveys in 51 countries, 58% deficits for double orphans (Ainsworth & Filmer, 2006)
  • 19 DHS surveys in 10 countries found significantly lower enrollment rates (Case et al. 2003)
  • UNICEF analysis in 24 countries also found wide varionation; as does another 6 papers on 7 countries

Orphans and HIV risk

  • Two studies in Zimbabwe documented a higher rate of reproductive health problems among adolescent girls who are orphans than among non-orphan girls (Gregson)
  • Earlier sexual onset for females in Zimbabwe & among males and females in South Africa (Gregson; Thurman)

(Adato, NIH/USAID OVC Mtg, 2008)

evidence of vulnerability o vc3
Evidence of vulnerability: OVC

Orphans and food security/nutrition

  • 8 studies find orphans worse off
  • CHS data from 6 southern African countries found no disadvantage (C-SAFE/WFP)
  • New DHS data analysis from 5 ESA countries finds wealth meain predictor of nutrition, but discrimination under certain circumstances in 3 countries (Stewart 2007)

Orphans and poverty

  • 10 studies poorer HHs, 21 studies richer HH (Ainsworth et al 2006)
  • New DHS data analysis from 5 ESA countries: orphans not represented in poorest HHs found (Stewart 2007)

(Adato, NIH/USAID OVC Mtg, 2008)

what do we conclude evidence of vulnerability o vc
What do we conclude?Evidence of vulnerability: OVC

It depends!


  • Poverty: major determinant
  • Household structure: blended HHs or not; relationship of orphans to HH head, age, whether mother deceased
  • Uncontrolled external factors:
    • Nature & extent of a particular need can vary by time & place
what do we conclude evidence of vulnerability o vc1
What do we conclude?Evidence of vulnerability: OVC

Wait, who are we talking about here?


  • Age?
  • Gender?
  • Orphan group compounded with HIV disease?

Type of orphan

  • Cause of parental death?
  • Single? Double? Maternal? Paternal?
empirical definition of orphans
Empirical Definition of Orphans
  • Systematic review of psychological and health issues among orphans affected by AIDS
  • 383 studies included

(Sherr in press)

empirical definitions of orphans
Empirical definitions of orphans

Research concerning orphans:

  • Lack of standardized definitions of orphans and inclusion of paternal/maternal orphans
  • Variance in cut-off ages (15 to 19)
  • No data from any study could be verified accurately against data from another study

(Sherr, in press)

what do we conclude evidence of vulnerability o vc2
What do we conclude?Evidence of vulnerability: OVC

Father figures: the progress at school of orphans in South Africa

  • “If two studies in the same province of South Africa disagree as to whether the death of the father, as well as the mother, impacts directly on the progress children make in their schooling, we lack the knowledge needed to prescribe solutions for Africa as a whole.”

(Timaeus& Boler, 2007)

what do we conclude evidence of vulnerability ovc
What do we conclude?Evidence of vulnerability: OVC
  • More data is needed with adequate controls & definitions
    • Need targeted samples or very large samples

An example from the field

(OVC TE Kenya Data, Thika, 2007)

what do we conclude evidence of vulnerability ovc1
What do we conclude?Evidence of vulnerability: OVC
  • Need increased understanding of the causal pathways
  • Are we spending too much time making the case that orphans are a risk group?
    • Bias towards comparing orphans and non-orphans
  • Absolute size of impact may be small compared to other gaps: (e.g., Urban/rural & Poverty)
    • No where were orphans 100%
  • Enough evidence to require attention to orphans; not enough evidence to target orphans exclusively

Child Vulnerability

  • Is determined by:
  • history
  • prevailing conditions
  • personality/temperament
  • support
  • arrangements post-disturbance etc
  • - Not necessarily by a particular experience or membership of a specific category

(Richter, 2006)

targeting programs
Targeting Programs

Age Considerations

  • OVC are defined as under age 18
    • No longer vulnerable at 18?
    • Age verification difficult
  • Tendency towards serving primary age group
    • Quick fix
    • Majority of orphans are adolescents
targeting programs1
Targeting Programs

Unintended Consequences for OVC

  • Increasing their vulnerability
    • Stigmatization
    • Preferential treatment can cause jealousies
    • Higher marginalization
    • Community members aim to be eligible for services
    • Community members forsake responsibility of OVC to NGOs
targeting programs2
Targeting Programs

Labeling children as OVC

  • People at the community level often pick up labels from agency documents, discussions, and presentations and begin to use them.
  • Learning to use the same jargon as those who control resources is a basic skill used by people from grassroots to international levels to gain access to resources.
  • However, problems begin when people begin to use “OVC,” “CABA” (children affected by AIDS), or other terms to refer to actual children. The result is stigmatization of the children intended to benefit

(Williamson, 2008)

targeting programs3
Targeting Programs
  • Global mobilization around AIDS-affected children important, but poses dilemmas concerning accuracy, equity and stigma
  • Policymakers, donors & programmers should avoid imposing specific eligibility criteria as to which vulnerable children and households should be targeted for assistance.
targeting programs4
Targeting Programs

A solution?

  • Promote community involvement in decisions about who should receive program services
  • Avoid explicitly targeting orphans or HIV-affected households
  • Avoid using the label OVC to refer to children & discourage the community from doing so
  • Target the most vulnerable by using a locally appropriate combination of indicators, such as:
    • Household poverty severity
    • Prime-age disability
    • High dependency ratios
community identification an example from the field
Community identificationAn example from the field

(OVC TE Kenya Data, Kilifi, 2007)


Strategies for Intervention

  • Strengthen and support the capacity of families to protect and care for orphans and vulnerable children by prolonging the lives of parents and providing economic, psychosocial and other support

2. Mobilize and strengthen community-based responses

3. Ensure access for orphans and vulnerable children to essential services, including education, health care, birth registration, and others

(OVC Framework, 2007)


Strategies for Intervention

4. Ensure that governments protect the most vulnerable children through improved policy and legislation and by channeling resources to families and communities

5. Raise awareness at all levels through advocacy and social mobilization to create a supportive environment for children and families affected by HIV/AIDS

(OVC Framework, 2007)

service delivery
Service Delivery

A Numbers game

  • 3 = 1
    • Primary Direct Support equals OVC who are counted as receiving PEPFAR funded or leveraged support in three or more of the core dimensions of OVC services
  • Recognizes that most effective interventions are multi-sectoral
  • However, issues of Quantity vs Quality?
service delivery1
Service Delivery

A Numbers game

  • Double counting
    • Same child counted as served twice across and within organizations
winterveldt hiv aids project south africa
Winterveldt HIV/AIDS Project South Africa

“During the period between June 2006 -June 2007, the project directly serviced a total of 549 OVC.”

Winterveldt HIV/AIDS Project, Draft Case Study

service delivery2
Service delivery

What’s coming:

  • OVC Databases with unique id #s
  • Increased data quality assessments

But, still, there are issues with verification….

  • Do large programs even know?
an example from the field
An example from the field

“All 20,000 children supported by our program receive annual health vaccinations and home visits from a trained CHW”

OVC TE Kenya Evaluation Data, Kilifi

service delivery3
Service delivery


  • Services given to child should also be made available to adult caregiver
    • Healthcare, psychosocial support
    • Note: Key Recommendation for OVC care but often won’t “count” as an OVC service
  • Serving the needs of ALL children in the home
  • Sustainable services
    • e.g., community gardens
  • Graduation?
government protection
Government protection
  • Institutions:
    • NO! NO! NO!
    • Many children actually have a surviving parent or extended kin who could care for them
    • Potentially detrimental to child development and adult community reintegration
    • Expensive
    • “From charity to profit making”
    • Existing institutions needs regulations and plans to reintegrate children
government protection1
Government protection
  • Government support structures & social service opportunities
    • Social Workers
    • Access to social grants & cash transfers
    • Is the foster care system in the US “sustainable?”
community based care
Community-based Care
  • Avoid romanticizing the situation
    • “Traditional system of fostering”
    • Urbanization, migration
    • Increasing primacy of nuclear family
    • Recognize and address stigma in interventions
      • OVC assumed or actual behavioral & emotional problems
      • Cause of parental death
      • Poverty
      • NGO support
community based care1
Community-based Care
  • Community committees
    • Apply participatory approaches
    • Don’t provide external resources to community committees until they invest internal resources
  • Care for the volunteer
    • Compassion burn-out
    • Transference of burden

(Williamson, 2008)

what works
What works?
  • Impression is that, until recently, donor & NGO emphasis has been on mounting an urgent rather than an effective response
  • From a scientific perspective, most evaluations of OVC programmes have been poorly designed, conducted, reviewed and disseminated
  • Very substantial resources are now going into OVC programs
  • Need for scientific evidence concerning the effectiveness of OVC programs

(Gregson, NIH/USAID OVC Mtg, 2008)

way forward
Way Forward
  • Which interventions meet the needs of AIDS affected children? (without causing further stigma)
  • Which interventions are most effective at meeting the needs of both children affected by AIDS as well as the majority of highly vulnerable children?
  • How do we know it works? Need to:
    • Establish Criteria for success for various approaches
    • Ensure cost effectiveness.
    • Ensure benefits are sustainable
    • Apply rigorous investigation methods
a new term
A new term?

Highly Vulnerable Children (HVC)

  • Those children under 18 whose safety, wellbeing or development is at significant risk due to inadequate care, protection or access to essential services. Includes:
    • Orphaned or those who receive inadequate adult support because of death, abandonment, economic distress, or chronic illness
    • have HIV/AIDS or are suspected of having hiv;
    • are directly affected by armed conflict;
    • live outside of family care;
    • or in some other way have suffered from a collapse of traditional safety nets in their community.

(USAID first annual report to congress, Aug 2007 )

All for now….

Enjoy the Festival…