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What happens when the donors withdraw? Community Based Organisations for HIV/AIDS and the World Bank in Zambia Aisling Walsh 1 , C Mulambia 2 , J Hanefeld 3 , R Brugha 1 , G Walt 3 1 Royal College of Surgeons in Ireland 2 Institute of Economic and Social Research, Zambia

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What happens when the donors withdraw?

Community Based Organisations for HIV/AIDS and the World Bank in Zambia

Aisling Walsh1, C Mulambia2, J Hanefeld3, R Brugha1, G Walt3

1 Royal College of Surgeons in Ireland

2 Institute of Economic and Social Research, Zambia

3 London School of Hygiene and Tropical Medicine



Irish Aid DANIDA




Health 20/20



HIV policies and structures put in place from 2000

Importance of CBOs in Zambia for provision of advocacy and support services:

30% of VCT services, 80% treatment care & support, 70% OVC

75% are local, 25% international

World Bank MAP in Zambia $42m (2003-2008)

Zambia National Response to HIV/AIDS project (ZANARA)

Community Response to AIDS - 35% of grant

Other funders – PEPFAR (62%) and Global Fund (16%) (2007)

Loan offer (2008) of $20m rejected by Zambian Govt



Studies on WBMAP in Zambia have focused on:

Predicting what would occur with closure of MAP (Siamwiza, 2007)

The wind down period and immediate aftermath (Hanefeld et al)

An internal World Bank evaluation (2009)

Need for evidence on effects 2+ years after cessation, when deeper effects likely to have emerged.


Study aim: to produce evidence on what was the current status and activities of these CBOs in Mumbwa two years following MAP/CRAIDS cessation.

What were the range and scale of their activities at district and community level?

How had these been affected by cessation of CRAIDS funds?


A - provide evidence to enable planning for future support to CBOs to deliver HIV and AIDS care and support services

B - provide a voice to CBOs, community/district stakeholders on activities and needs of CBOs for HIV and AIDS.


Methods and sampling

One district – rural Mumbwa

Consultation with NAC and DACA

Mapping – national and district level

39 in-depth interviews

- All CRAIDS funded CBOs (18)

- District/Community AIDS Task Force members (10)

- National level stakeholders (11)

Analysis: thematic approach (ongoing)

results 1 funding from craids to the funding gap


From CRAIDS to the funding gap



ALL CRAIDS funded CBOs existed prior to CRAIDS

9 CBOs had no external funding prior to CRAIDS – survived from IGAs

Funders pre-CRAIDS: PAM, HEIFER Intl, CHAZ, Millennium Change Corporation, NGOCC, CDF - reportedly no longer funding CBOs in Zambia in 2010


Overall view of CRAIDS was very positive (all stakeholders).Initial target of 350 projects – actual number funded was 1,800

Most heard about funding through DACA and most received funds between 2005-2007

Size of grants ranged from K35m to K72m – some in lump sums, others in installments


More accessible than other funders

Some CBOs unhappy with conditions on services, but necessary for even spread and availability of services throughout the district


CRAIDS cessation

CBOs: most clear about timing of grant from outset but some told that they may get another installment.

District and national: poor communication about CRAIDS closing (district & national)

Examples of districts where no trace of CRAIDS remains and where the DATFs no longer exist (district and national)

Current funding opportunities

Scarce and definite decrease from 2008

Most CBOs not aware of other sources

World Vision and Child Fund

CHAZ – funded 4 CBOs in past, but currently ‘on a break’

Incorrect information on ZNAN conditions– member for 3 years with audited accounts

Little knowledge of PEPFAR or their grants

MCDSS: funding scheme for OVCs

social cash transfer scheme

results 2 cbo service provision



Services provided by CBOs

Home Based Care: nutritional support, counselling, cleaning, washing

Transport: (mainly bicycles) to clinic/hospital, HBC

Sensitisation activities: for prevention, reduce stigma and awareness campaigns

OVC Support: subsidies for nutrition support, school uniforms, school fees

Effectiveness and sustainability of IGAs?

Most CBOs engaged in IGAs such as

animals, farming, cooking, knitting, hammer mills

Enabled some CBOs to open a shop and others

used farming to generate food for HBC.


Effectiveness and sustainability of IGAs? (contd)

Not always sustainable, due to lack of infrastructure – roads, bridges and small local markets

Competition amongst IGAs frequently cited

Only 2 reported IGAs enabled services

levels to be maintained at CRAIDS levels

“Each time a community decided on an IGA, then it was making returns, then competition came in from new comers. The outsiders wanted to do also exactly the same thing. So they lost on the market.” (District stakeholders)

“With the hammer mill the income is very slow because we are in the midst of people who have electric hammer mills that are even more efficient… so that difference kills our business.” (CBO rep)


Current gaps in services due to CRAIDS cessation

All CBOs funded by CRAIDS are still in existence. BUT

Reductions in service provision

Transport the biggest obstacle

Decrease in nutritional support

“For the OVCs there has been a change from when CRAIDS was funding us. There was a feeding programme. Right now we are failing to feed the children. We are also finding it very difficult to keep 100 children at school. Some of them have stopped coming to school.” (CBO rep)

Decrease in numbers supported through HBC

Report of an imbalance of emphasis on treatment and prevention services

Other schemes to improve service provision

MCDSS food security programme; women and development programme; public welfare assistance scheme (for school fees and uniforms)

MoEd: school feeding programme

results 3 capacity building of cbos

capacity building of CBOs


Capacity Building of CBOs

Volunteers are at the heart of care and support services

Range in numbers from 10-100 per CBO.

Most reported a reduction in volunteer numbers

All CBOs reported capacity being built through CRAIDS

Training for psychosocial counselling, adherence support, peer education

Business skills

Capacity continues to be built internally but

Some skills lost over time – changing technical/medical knowledge


Capacity Building (contd)

  • Some specified the need to tailor training to suit needs of specific CBOs
  • Some volunteers have been with CBO for up to 10 years
  • Comparative advantage
    • - people prefer to be counselled in the community
    • - praised for being the “only way to fight the pandemic” through community determination and hard work.
    • - care givers have closer links as they live within the community, in essence they are the community
  • Some received allowances during CRAIDS
  • Decrease in morale – due to lack of materials, work overload
results 4 coordination and planning

Coordination and planning


District Coordination Structures for HIV and AIDS

DACA held in high regard by CBOs

– advises, monitors, coordinates

Importance of a local leader with in-depth local knowledge.

Office of DACA located in DHO meaning now firmly situated within government health system

Uncertainty about DACA/DATF continuation (mid 2010) and lack of funding meant more difficult to carry out functions

Funding now secured through GF for next 2 years?


District Coordination Structures (contd)

  • Recruitment of DACAs a priority for NAC in new strategic framework
  • National level: onus should be more on DATFs as a body
  • CRAIDS regional coordinator: not all CBOs aware of existence and lack of understanding of their roles.
  • CATFs:
    • did not receive CRAIDS funding for services.
    • difficulties in covering catchment areas.

Cooperation with other providers

  • Many positive relationships – CBOs and clinics: reciprocal arrangements and referrals.
  • Cooperation with area associations outside HIV – Women’s Associations and hospital associations
  • Some CBOs did not work with other providers – lack of awareness of other CBOs, others for World AIDS Day only

Coordination and planning (contd)

Monitoring and Evaluation

NARFs and HMIS exist in parallel but capture different indicators

Reporting a challenge – distances and lack of fuel for DACA to collect forms

Communities more motivated when monitored

Lack of awareness of NGO Act 2009 but where CBOs were aware, general positivity

Numbers of CBOs registered with DATF increased since 2008


Conclusions (1)

A.1Conduct situation analyses of community-based AIDS care and support services and needs in all districts

Map AIDS care and support service provision

Organisations: CBOs, NGOs and Government services

Services: Home Based Care, food supports, support to OVCs, Counselling, treatment adherence, Income Generating Activities

Assess community needs for services

Target group in need of services (PLWAs, OVCs) – numbers and distribution

Numbers receiving / not receiving services – coverage levels

Map existing funding sources – UNAIDS?

Assess CBOs’ capacities to deliver care & support services (+ do IGAs) – DATFs?

Map links between CBOs and district health facilities


Conclusions (2)

A.2Maximise use of existing funding sources

Communicate existence and mechanisms for accessing funding sources

Funders to make funding conditions explicit to CBOs

Implement recommendations by

working through the DATF and CATF (note success of CRAIDS)

using media such as newspapers and local radio more effectively.


Conclusions (3)

Options for funding and supporting AIDS Care and Support

A. Mainstream HIV care and support services within broader poverty alleviationfunding channels - however, ensure that:

The needs of PLWAs and families are prioritised

CBOs can access funds and support to carry out their activities

Continued support to DATFs and CATFs to carry out their coordination activities

OR / AND ?

B. Retain a separate funding stream for community AIDS Care and Support activities

Poverty alleviation activities can be through generic or AIDS-specific channels

AIDS-specific / specialised support activities through these channels



What are the community-support schemes run by the MCDSS and the MoEd?

Are they accessible to CBOs? To PLWAs? Do they meet their AIDS care and support needs?

Should community responses make special provision to target communities based on needs for AIDS care & support

Need for (feasibility of) conducing community situation analyses of AIDS Care and Support needs and services? Other options?

What should be in the AIDS community response package?

HBC, Food, Counselling, Treatment adherence, support to OVCs

IGAs (income generating activities) – need for lesson learning

Capacity-building (it is possible) + create enabling environments



Should funding go to CBOs to do AIDS Care and Support?

Defining what is a CBO

If so, through DATFs / district AIDS bodies or

Through Local Government bodies?


what do we mean by it?

Are there some community AIDS Care and Support activities that should be sustained through resources from the national level (Govt and Donors)?

Reporting, monitoring and evaluation?

How well is the NARF (National AIDS Reporting to the NAC) working?

Are NARF data reported, analysed and acted upon?

Would there be value in evaluating the NARF M&E reporting process?

other more important questions for discussion