Orphans and Vulnerable Children in sub-Saharan Africa

1. Orphans and Vulnerable Children in sub-Saharan Africa Tonya Renee Thurman, MPH, PhD Social Impact of AIDS Class lecture, April 11th 2008

2. Overview Who are OVC? • Terminology • Definitions • Prevalence & estimations • Evidence of “vulnerability” Considerations for programming • Targeting OVC • Key Strategies and Considerations • What works? • Way Forward

3. Terminology • AIDS Orphans • CABA (Children Affected by AIDS) • Orphans & Vulnerable Children (OVC)

4. 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

5. 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.

6. 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

7. 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).

8. 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)

11. Cause of Orphanhood Over 12 million children in SAA have been orphaned by AIDS Source: UNAIDS and UNICEF Estimates, 2006

12. Percent Orphaned by AIDS and Other Causes Source: UNAIDS and UNICEF Estimates, 2006

13. “Orphans became “shorthand” for the cumulative community impact of AIDS Foster 2006

14. The increase in orphans lags HIV prevalence by about 10 years HIV prevalence orphans

15. 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

16. 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

17. 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.

18. 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.

19. 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.

20. Current Efforts towards total numbers of OVC OVC Estimates: Model 1 (LaTour, USAID Office of the Global AIDS Coordinator, NIH/USAID OVC Mtg, 2008)

21. Current Efforts towards total numbers of OVC OVC Estimates: Model 2

22. Current Efforts towards total numbers of OVC OVC Estimates: Model 3

23. 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.

24. Global estimates: Considerations Absolute numbers vs Percentages

25. 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)

26. 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)

27. 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.

28. Problems commonly associated w/ OVC REDUCEDINCREASED 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)

29. 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)

30. 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.

31. Evidence of Vulnerability: OVC Issues facing children living with an ill caregiver Education • 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?

32. 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

33. 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.

34. With whom do orphans live?

35. With whom do orphans live? Institutions • 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)

36. 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

37. 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)

38. 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)

39. What do we conclude?Evidence of vulnerability: OVC It depends! On: • 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

40. What do we conclude?Evidence of vulnerability: OVC Wait, who are we talking about here? Demographics • Age? • Gender? • Orphan group compounded with HIV disease? Type of orphan • Cause of parental death? • Single? Double? Maternal? Paternal?

41. Empirical Definition of Orphans • Systematic review of psychological and health issues among orphans affected by AIDS • 383 studies included (Sherr in press)

42. 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)

43. 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)

44. 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)

45. 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

46. Child Vulnerability • Is determined by: • history • prevailing conditions • personality/temperament • support • arrangements post-disturbance etc • MOST ESPECIALLY BY PARENTAL SUPPORT / DISRUPTION • - Not necessarily by a particular experience or membership of a specific category (Richter, 2006)

47. Targeting OVC Programs

48. 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

49. 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

50. 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)