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FAITH BASED ORGANISATIONS HIV/AIDS WORK SURVEY MALAWI REPORT 2003 1. Institutional Framework and Set-Up of FBOs o The National Strategic Framework in recognition of the work that FBOs are carrying out on HIV/AIDS in Malawi placed them as core implementing agencies working directly with communities. Efforts have been made to strengthen partnerships among religious organizations with regard to planning, implementation, monitoring, evaluation and resource mobilization. o There is an office responsible for religious affairs in the Office of the President and Cabinet. o In addition, religious groups have formed umbrella organizations including Episcopal Conference of Malawi (ECM), Moslem Association of Malawi (MAM), Malawi Council of Churches (MCC), Christian Health Association of Malawi (CHAM) and Charismatic and Pentecostal Association of Malawi (Chapel), under which the majority of FBOs operate. These umbrella organizations support collective coordination and collaborative efforts including planning. In 2001, o a State Faith Community Task Force was formed to enhance collaboration between Government and FBOs in Malawi. o As a follow-up to the November 2001 WCC HIV/AIDS Conference in Nairobi, a churches conference took place in November 2002 where all churches and their umbrella organizations came together to break the silence and address the challenges of HIV/AIDS. This conference was a result of the cooperation of the three major church mother bodies of MCC, ECM and EAM in collaboration with the Norwegian Church Aid. 2.0 SPREAD OF FBOs IN MALAWI, GOVERNANCE AND HUMAN AND FINANCIAL SYSTEMS CAPACITY. 1 The mushrooming of FBOs in all parts of Malawi cannot be overlooked. . Faith leaders and their organisations are well respected and therefore command a strong following. In addition religious organisations , individually and together have a deep geographical penetration. This presents great advantages to intensifying interventions and to increasing the reach and impact of these interventions. Many FBOs have recognized governing structures. However, many do not open up to external professional membership of their governing bodies while others still remain very conservative with bureaucratic structures. This has dented the face of the FBOs as many remain very closed to open up particularly to books of accounts. The human and management systems capacity have been affected much by unavailability of qualified personnel in these institutions. However, it is seen as a common tradition in most FBOs recruiting unqualified personnel and in some cases based on ‘relationships and trust’ which has compromised quality of work being provided. As an example of one of the FBOs human resource capacity, CHAM’s current capacity of selected professional health workers from its 159 members is as presented below: PROFESSIONAL HEALTH WORKERS IN CHAM Cadre Recommended Actual % Medical Officers 36 15 41.6% Clinical Officers 102 69 67.6% Medical Assistants 271 80 29.5% Nurses 1995 856 42.9% Dental Tech/Assistants 152 10 6.6% Laboratory Tech/Assistants 152 51 33.6% Pharmacy Tech/Assistants 276 19 6.9% Patient Attendants 234 413 176% The overall picture of the staffing situation in CHAM has 7664 recommended posts of which only 4746 (61.9%) posts are filled. Amongst the professional cadres, only 33% of the recommended posts of the approved establishment are filled. Several reasons are contributing to this situation which among others are: Many FBOs are very rural based therefore difficult to attract qualified personnel. 2 Qualified personnel particularly health workers are scarce on the market. Competitive packages – other NGOs of which some are faith- based are providing very high perks. The problem of HIV/AIDS: attrition resulting from HIV/AIDS related deaths is very high at the moment. Current outputs from all health training institutions do not match the demand for personnel in the health sector. 1.1 INSTITUTIONAL SET UP OF FBOs Some FBO’s have structures for implementation of HIV/AIDS where coordinators/ supervisors are in place but this applies to only a few. In most of the FBOs, structures are just being put in place. In October 1999, a wide array of stakeholders in Malawi developed the National Strategic Framework on HIV/AIDS: 2000 – 2004 (NSF), outlining the national response to the epidemic. National AIDS Commission (NAC) has been tasked to coordinate the national response including provision of policy and leadership on the issue. Strategies and Policies to guide activities of HIV/AIDS activties are found within some organizations e.g. World Relief Malawi, AHS, Anglican Diocese of Northern Malawi, LISAP Project (Livingstonia Synod) among others. Other FBOs still do not have policies/strategies to guide them in the endeavor to fight against HIV/AIDS. 3.0 MAJOR ACTIVITIES PURSUED BY THE CHURCHES In responding to the epidemic Faith Communities have addressed both prevention and impact mitigation. The study has strengthened the knowledge that FBOs are working in many areas of HIV/AIDS, trying to stop its spread among the children of God, but also dealing with the effects for the infected and affected persons. 5.2.1 EDUCATION AND TRAINING Prevention interventions have included information campaigns, but these have not been adequate in part because of judgemental approaches to interventions and in part as a result of emphasis on moral teaching. Almost all FBOs considered training of the providers of HIV/AIDS services as important. Target groups were also included in different training sessions of all the sub themes to equip them with knowledge, 3 skills and positive attitudes when handling HIV/AIDS issues. The number of training sessions for each institution depended on availability of funds, which determined availability of the other resources. All FBOs considered the importance of the clergy/sheiks and included them in the trainings they have conducted. Due to inadequate funds, some institutions trained only a few. From the findings, we realize that FBOs would like to conduct more training sessions but due to inadequate funds, some institutions trained only a few. Many FBOs expressed the need for more consistent and encompassing training programmes, with more emphasis on the outputs. Faith communities would be more effective if they at the same time revised their theological positions on issues of sex and sexuality. 5.2.2 ADVOCACY Groups of people in all FBOs are engaged in disseminating HIV/AIDS messages to people in their areas regardless of religious affiliation. Some FBOs involve target groups in planning programmes as this helps with ownership of the activities. The advocacy groups are gender based in all FBOs. FBOs have been called upon to collectively respond to the HIV/AIDS situation in Malawi. They acknowledge the need that all are present, actively participate in and coordinate with regional and national efforts, donor community and government in the fight against HIV/AIDS.The advocacy work is also important inside the FBOs. The Clergy/Sheiks still need to be oriented and re-oriented on HIV/AIDS issues, values and ethics and create awareness against stigmatization using the pulpit and other channels and teach people and children to break the silence on issues of sex and sexuality, prejudice and fear of HIV/AIDS. Many say that the issue of stigimatization and condemnation is still high among some leaders. Despite that some FBOs are unclear about advocacy, there are others who are active in FBO work. 5.2.3 ORPHAN CARE: 4 Most FBOs are providing care to orphans. All orphans in an area regardless of the cause of death of their parents are supported. This is to remove stigma and discrimination of those whose parents died from HIV/AIDS for example the Muslim Association of Malawi (MAM) has orphanage centers but the names were changed to Islamic Welfare Centers because the former was regarded discriminatory. Volunteers are providing care to orphans in centers where orphans are being kept. Most FBOs have trained foster families and orphans are being kept in the homes with other members of the families. All the support food, clothes, educational materials including fees is given while at home. Some programs in some FBOs are targeting the orphan families in crisis (OFIC) families headed by children, grandparent and sick single parent. The programs aim at identifying and supporting families on emergency basis to improve their livelihood and rehabilitate their families in a secure and sustainable manner. Due to abuse of orphans and the magnitude of the problem, many work through institutions even though they would have preferred a community based solution. 5.2.4 HOME BASED CARE The aim of this program is to provide care and support to people living with HIV/AIDS, carers and orphans. Almost all FBOs have HBC programs in their areas targeting the infected, other chronically ill patients, and the affected – guardians and vulnerable children. Volunteers –most women and a few men work hand in hand to take care of the sick people. They provide simple treatment, feed them, train guardians and ensure hygiene of body and environment. They also share the word of God to encourage positive living. Constraints and Challenges Increasing numbers of patients and orphans requiring Home Based Care. Inadequate resources – funds, materials transport for follow-up Reduced numbers of male volunteers. Increasing numbers of volunteers drop outs due to lack of incentives. 5 Inadequate training Some institutions have mentioned issue of dropouts because people are not able to fend for themselves while they are providing voluntary services to the chronically ill. Increased numbers of HIV/AIDS patients and orphans if VCT is not intensified. There will be many more people getting infected. The PLWAs also need a lot of counseling so that they do no infect other people and avoid becoming pregnant. This will reduce the number of babies born with HIV/AIDS. Therefore, if every FBO intensifies VCT services and efficiently care for PLWAs, new infections will be reduced. Resources to effectively provide HBC to HIV/AIDS patients are not adequate because they come from development partners and some from NAC. FBOs are not linked with others, as a result some FBOs have more than others. FBOs have to plan how they will fend for themselves in future. The numbers of male volunteers are small in many FBOs. There seems to be fewer advocacies that HBC is everyone’s role. 5.2.5 VOLUNTARY COUNSELING AND TESTING (VCT) Most FBOs carry out counseling services while only a few do the testing as well. The testing has not yet been taken to the communities. So far only one NGO outside the health facilities does testing otherwise testing is still very much clinic based making it unaccessible to the majority. Trained men, women and youths are used for counseling. Some FBOs have used VCT as a behavior change intervention tool, targeting males, females, orphans and youths e.g. The Salvation Army. Some schools are using headmasters, headmistresses and teachers to counsel the students and other teachers. The counselors are advised not to scare people with HIV/AIDS messages. Those tested are followed up so that those who tested negative are encouraged to remain negative by being living responsible while those who tested positive are advised to have positive attitude and are advised how nutrition and a healthy lifestyle can assist to prolong their life. 5.2.6 SCREENING OF BLOOD 6 Blood is properly screened for the virus before transfusion. In most of CHAM hospitals blood is screened using trained personnel. The effort is sometimes being hindered because of inadequate reagents and use of untrained laboratory personnel. 5.2.7 PMTCT This is a program that is coming up to prevent further spread of disease between mother and child. A few FBOs are providing the service of which are five out of 159 CHAM facilities with assistance from UNICEF. The mothers also receive as prophylaxis isonyazide and bactrim. HIV positive mothers are encouraged to only breastfeed for the first 6 months to reduce the risk of transmission of the virus. This is a result of research in South Africa. CHAM is planning to extend this service beyond the five facilities currently providing the service. Mother to child transmission of HIV virus is a growing problem in Malawi that requires serious and urgent attention. 5.2.8 INFORMATION, EDUCATION AND COMMUNICATION Almost all FBOs print and distribute IEC materials consisting of leaflets, brochures, comics and booklets on HIV/AIDS to everyone regardless of religious affiliation and sex. Examples are World Life Ministries International, Evangelical Lutheran Church etc. HIV/AIDS messages are also disseminated during religious meetings, preaching sessions targeting males, females and youths. Most FBOs have drama and singing groups in place who take HIV/AIDS messages to all communities in their catchment area. It is pleasing to note that many FBOs are printing and distributing HIV/AIDS IEC materials. It is however, not known if the materials are of acceptable standards. The Faith communities have over the years conducted behaviour change communication activities especially for the youth. Again these efforts are affected by lack of adequate resources. But most important, teaching responsibility tends to be limited to the members of the clergy and those in leadership positions, excluding the general membership in most cases. In addition, some Faith 7 communities do not have the leaders who should project the appropriate models of moral behaviour. 5.2.9 TREATMENT INCLUDING ARV THERAPY Opportunistic infections and sexually transmitted infections are treated promptly and each prolongs life. Community health workers have been trained on how they can treat these infections. Churches/Mosques often promote the contribution that traditional medicine and wisdom can offer as a therapeutic resource. The 7 dioceses of the Episcopal Conference of Malawi is an example of using herbal medicines treatment. Some facilities under FBOs provide Prophylaxis treatment of INH and Cotrimoxazole to HIV positive mothers with their babies. In 5 CHAM facilities, they also receive Niverapine. Collaboration is occurring in some facilities where the FBO is working in close cooperation with Ministry of Health and Population (MOHP) and MSF in treating HIV/AIDS patients. An example is Bilal Clinic in Chiradzulu under MAM. Some FBOs have reported using community health workers in treating Opportunistic Infections (Ols) and Sexually Transmitted Infections (STIs). What is not known is the competence of these people to handle the patients. It is not known if they have been given any treatment guidelines for treating the Ois and STIs and if they are regularly supervised by the FBOs. The Episcopal Conference of Malawi is using herbal medicine treatment on PLWAs. However, there is need to expand what the Episcopal Conference of Malawi is doing to other FBOs. ARV therapy still remains a distant hope for the majority poor Malawians. ARV therapy is still very much Government controlled and provided at a high fee of $28/month in two central hospitals and only one CHAM unit. 5.2.10 ABC FOR SAFE SEX PRACTICES All FBOs are addressing this issue to prevent further spread of HIV/AIDS. They encourage abstinence in a more relevant and practical way among youths and the importance of the “why wait” stand. The issue of promoting use of condoms is still difficult for the FBOs. Faith communities maintain a strong non-permissive position counterbalanced against the more ethical and rational-scientific position of the government. Most feel that by promoting the condoms, 8 they encourage promiscuity. There is also a reluctance to give information about condoms. All the FBOs talk about condoms, meaning the male condom. The female one is out of question. FBOs leaders in Malawi have started to open up the discussion, realizing that it contains a long row of ethical dilemmas that cannot easily be overlooked. They have asked for arenas to discuss the issue of condoms in a more holistic and gender sensitive way. Many FBO leaders realize that their parishioners ask for guidance about condoms from other NGOs. Adults are encouraged to have one partner and to be faithful with each other. Some FBO’s promote the use of condoms inside marriage and in cases of promiscuity. 5.2.11 PLWAS FBOs recognize and salute those people who have come out to share their personal counts as PLWAs. There is need to provide PLWAs with a safe and conducive environment where they can continue to share their fears, agonies, pain and emotions. In HIV/AIDS, it is not only the condition that hurts most, but also the stigma and possibility of discrimination and rejection, misunderstanding and loss of trust. Some FBOs have programs for PLWAs. Most active members are those living with HIV/AIDS. They hold meetings to share experiences, training each other in drama and counseling techniques. They also encourage those who are HIV positive to live positively. Some FBOs have Relief and Development programs e.g. Word Live Ministries International under the ICOCA project, which has 500 beneficiaries. They give each one of them 25Kg Maize per month and 5Kg beans/month. Maize and legumes have been grown to distribute to beneficiaries. It is unison among the FBOs that PLWAs must not be discriminated against; they as everyone else must be loved, shown compassion and be supported in a holistic way physically. Spiritually, they must be given comforting word of God. Clergy/Sheiks are encouraged not to preach stigma to PLWAs but to use PLWAs in all activities of the church. It is acknowledged that there are still many elements of stigmatization of PLWAs inside the FBOs. 9 5.2.12 YOUTH ACTIVITIES Young people are the most vulnerable to the HIV/AIDS epidemic. About 46% of all new adult infections occur in youths aged 15-24. Of these, 66 % are young women. Peer pressure, certain cultural practices and limited access to information about sexual and reproductive health risk them to HIV/AIDS. Most FBOs have programs for youths. They encourage them to form anti-Aids clubs. Youth out of school train members and teachers on anti-Aids clubs. They provide recreational materials to the groups. They share HIV/AIDS information during youth meetings, campouts, rallies, and retreats. The main focus is on behavior change. An example could be the SDA church that reaches several thousand youths every year through drama and radio plays. Some youths are trained to share with others HIV/AIDS messages, train peer educators in life skills, and supervise educators in drama. They encourage each other on abstinence. This most outreaching programmes are found within the members of EAM. However, it has been observed that the issue of youth has not been fully addressed in the questionnaires. There is a general lack of adequate programs directed towards this most important group of Malawians, our window of hope. 5.2.13 GENDER/MAINSTREAMING In Malawi, men make most decisions and women are viewed to be inferior and hold lower status in society. This is enforced and worse in the FBOs. Some FBOs have started involving both men and women in activities of the church and community. In orphan and home based care, groups of men and women work together. Some FBOs have aimed at having equal numbers of males and females in groups and have moved away from specific women’s programs. Some FBOs have allocated specific activities to specific departments of the church in order to empower everybody. Some FBOs have girl’s brigades with special activities. HIV/AIDS messages and activities are shared with them. Gender mainstreaming assists to have activities of HIV/AIDS to the grassroots and should be expanded. It is a long way for the FBOs to 10 have a gender sensitive approach in their programs. Most of them seem to have no idea of what the term gender means. 5.2.14 PROGRAMS TARGETING WOMEN Women and the girl child are more vulnerable of getting infected by the HIV virus and other sexually transmitted infections owing to their positions in society. Some FBOs have programs targeting women and the girl child. There are Women Ministry departments where among other things, HIV/AIDS issues are discussed. Training and empowerment is done where women are involved in incoming generating activities. Also they discuss empowerment to fight the disease and to empower the girl child to say No to casual sex. This work will only succeed if men are sensitized in the same way and start to take care of their young boys and girls and guide them properly. 5.2.15 ADDRESSING HARMFUL CULTURAL TRADITIONS AND PRACTICES. Some harmful cultural traditions and practices have lead to the spread of HIV/AIDS amongst people especially women and youths e.g. Chokolo, kuchotsa fumbi and fisi. Some FBOs are working with traditional leaders to take a leading role in finding alternative harmless rituals at initiation ceremonies for youths to reduce spread of HIV/AIDS. The practice of herbal cleansing is becoming popular in some areas as opposed to sexual cleansing. Many FBOs are working with traditional leaders and some materials targeting traditional authorities are being developed. Workshops have been held with traditional leaders, healers, elderly men and women on HIV/AIDS. 6.0 CHALLENGES/WEAKNESSES FBOs are active in the fight against HIV/AIDS and are implementing a number of HIV/AIDS programmes at common level. However, they are still grappling with challenges such as: High turnover of Counselors and Volunteers Inadequate technical staff such as clinicians, nurses and Laboratory Technicians. 11 Lack of specialized personnel with skills in behaviour change. Capacity in operational research, rights based approaches to HIV/AIDS programming, mainstreaming gender in HIV/AIDS programmes, planning, management, monitoring and evaluation of HIV/AIDS programmes is also limited Coordination of HIV/AIDS training and capacity building of local training institutions is critical for sustainable capacity building. Harmful cultural practices which are health hazards e.g. wasting dead bodies. Poor information management system at all levels and poor information sharing. Documentation of activities and use of research information I for planning and decision making is still very poor in Malawi Poor collaboration with some international organizations who often bypass umbrella organizations resulting in duplication and work overload for member units. Donor conditionalities. Some development partners are not interested in certain HIV/AIDS interventions e.g. ARVS,PMTCT. Inadequate resources at implementation level Poor infection prevention practices at health facilities and community level. Compartmentalization of activities of the health facilities which makes sharing of resources difficult. Inadequate youth friendly activities and services. KEY CONSTRAINTS TO IMPLEMENTATION OF HIV/AIDS ACTIVITIES Considerable overt resistance still exists with regard to certain methods of HIV prevention and reproductive health e.g. condoms. Absence of an effective national coordination mechanism for collaborating with FBOs as a group. Limited participation of men in FBO activities, such as care and support activities. Limited resources allocated to FBOs (especially by international partners) commensurate with their scope of work. FBOs frequently do not have the human resource and technical capacity required to meet the complexity and challenges of implementing HIV/AIDS activities. 12 While FBOs have increased support for PLWHAs, changes in language and behaviour which cause despair and negative attitudes remain a challenge. Lack of understanding of mainstreaming gender and rights in FBOs. 7.0 A SWOT ANALYSIS OF FBOs IN MALAWI Strengths Weaknesses Opportunities Threats Dedicated/committed Lack of qualified Community Donor fatigue. staff. personnel. participation Labour market Church has Recruitment of . very small for strongest roots, unqualified staff. Spirit of qualified linkages and longest Programmes not volunteeris personnel. existing community totally linked and m in Competition with formal integrated with surrounding caused by management and each other. communitie international governance Competition s. FBOs inflicted structures. amongst FBOs. Political will. upon local FBOs. Strong programme Conservative/rigid Government High attrition of implementation governance interest to staff resulting background. structures. support from HIV/AIDS, Holistic care. Difficult to FBOs in greener National wide disclose financial HIV/AIDS pastures. coverage. resources. activities. Natural Deep geographical Lack of use of IT Donor disasters, coverage to help M & E and interest and drought. Well respected and accountability. trust in Unstable micro command a large Donor FBOs. and macro following dependency/ Peaceful economic Better quality of care Lack of local working environment. Willingness to care resources. environment Unfriendly for the suffering with Poor salary . external/foreign compassion structure. policies. Donor conditionalities. 8.0 LESSONS/BEST PRACTICES Participation of communities, particularly local leaders is vital at all levels of the project cycle. Consultation and collaboration must have no limit (with all stakeholders) Involving PLWA in IEC activities helps to reduce fear stigma and discrimination in addition to those involved. 13 Persons living with HIV/AIDS have been involved in AIDS service organizations as staff persons, volunteers and board members. In some localities, HIV-positive persons have set up their own organizations. At the national level, networks of persons living with HIV/AIDS have been established in many countries. Such networks also exist at regional and global levels. As well, persons living with HIV/AIDS have participated in ever increasing numbers in international conferences, thanks to scholarship programs and other special funding mechanisms that other organizations are providing. 10.0 AREAS OF POSSIBLE COLLABORATION BETWEEN FBOs AND VARIOUS FUNDING AGENCIES FBO and the funding partners should work as partners in the execution of all activities including HIV/AIDS. FBOs should not be parasitic but work in such a manner of mutual trust with the funding agencies for the benefit of those disadvantaged. As the adage says, ‘ Do not walk behind me for I will not see you, do not walk in front of me for I will not follow you, but let us walk side by side’ – thus funding partners and the FBOs have to look at each other as equal partners working to achieve a common goal. Some of the areas the two could work together include: Join hands in breaking the silence that still surrounds the epidemic and removing all forms of discrimination. Financial/technical assistance to support the implementation of identified programmes. Networking to ensure both FBOs and the donor agencies are linked to important areas for the benefit of both parties. Information sharing to ensure transparency, avoid duplication of activities and for successful implementation of activities. Capacity Building of the FBOs to ensure sustainability of programmes. Development of skills in the design and implementation of programs, including means for mobilizing and accounting for resources. Advocacy and lobbying particularly focusing at policies that will make us ‘as partners’ achieve our objectives. 14 Promoting establishment of HIV/AIDS testing facilities and encouraging youth and adults to test. Mainstreaming HIV/AIDS, Gender, Human rights into all development programs while at same time creating more effective mechanisms for mobilizing essential resources. Engaging in on-going collaboration and consultation with other stakeholders such as Government, and recognizing the good efforts that each is making in the fight against the epidemic. Revising some of the theological positions which seem to curtail effectiveness for example on matters of sex and sexuality, gender, PLWAs and understanding the HIV/AIDS epidemic Facilitate availability and provision of free ARVs to the majority who cannot afford so that productive life of the infected and affected is prolonged. 11.0 CONCLUSION The review shows that a variety of HIV/AIDS activities take place in the FBOs at the grass root level, especially in the area of care and support. But there is a general lack of consistent strategies, of consistent training, of a human rights approach and gender mainstreaming of activities. Lack of funds is listed as the main constraint and does also lead to inconsistency in capacity building. In all answers we see a will by FBO to do and assist more if funds were available. It is obvious that the attitude towards infected and affected changes and is constantly changing, but especially church leaders in HIV/AIDS should be trained. The FBOs ask to no longer be looked upon as a group of narrow minders, condemning people but as important partners for Government of Malawi in the fight against HIV/AIDS. One could say that there are two milestones that all the FBOs set as the most important; Availability of funds Consistent capacity building With these in place, the work against HIV/AIDS would be immensely strengthened. 15 Key Recommendations and Milestone for the Next Two Years There is need to strengthen the position and role of the State Faith Community Task Force as a coordinating structure for FBO HIV/AIDS activities. Intensify advocacy aimed at encouraging FBOs to fully maximize their comparative advantage in the fight against HIV/AIDS without compromising approaches by other partners (e.g. issues related to condoms and reproductive health practices). There is need to re-prioritize mobilization to support HIV/AIDS activities by faith based organizations. There is need to facilitate human resource and technical support for faith based organizations (i.e. project planning and management and ensure that they equally benefit from the various funding initiatives such as the Global fund on AIDS, TB and malaria. 16
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