WFP HIV/AIDS Programming in Malawi

By Jeremy Shoham, ENN

Households headed by the elderly may be vulnerable

This article was written based on a WFP consultation to Malawi in February 2005.

The WFP Malawi HIV/AIDS project started in November 2002 as a pilot project in four districts, targeting 7,500 HIV/AIDS affected households per year. During EMOP (Emergency Operation) 10290, between July 2003 and December 2004, the project expanded into 14 districts to support 27,818 households caring for the chronically ill (CI) and orphans, and 10,000 individuals. In the current PRRO (Protracted Relief and Recovery Operation), the project will target 22,750 households taking care of the chronically ill and those keeping orphans and other vulnerable children, 1,250 TB patients, 3,450 HIV positive mothers enrolled in the Prevention of Mother to Child Transmission of HIV (PMTCT) programmes, and 5,300 chronically ill persons. Project support will be in 12 districts.

The overarching goals of the project have been to maintain the minimum acceptable nutritional and dietary standards of PLWHAand other vulnerable groups through provision of information and services on food aid and health. Specific objectives are to:

• Improve the nutritional status of CI persons, including patients on Directly Observed TB Treatment (DOT) and PLWHAs on antiretroviral (ARV) treatment.
• Improve the short-term food security of households with CI persons and those taking care of orphans
• Strengthen the capacity of partner agency staff and community support groups to implement effectively comprehensive HIV/AIDS and nutrition related activities.

Programme targeting

The method of targeting for the programme was elaborated in guidelines produced by a consortium of INGOs, UN agencies and government ministries (JEFAP¹11).TheVulnerabilityAssessment Committee (VAC) report of February 2003 and National HIV/AIDS Surveillance report of 2001 were used to identify the most vulnerable districts in the country, meaning those districts with:

• High numbers of cases of HIV infection (above 4% according to the 2001 National HIV/AIDS Surveillance Report)
• High prevalence of AIDS cases
• High incidence of TB
• High numbers of orphans
• Food insecurity and low mean calorie intake per person per day
• Existence of an NGO capable of implementing HIV/AIDS activities and collaborating with other organisations in the district.

Priority Tribal Areas (TAs) were determined by the lead NGOs through meetings with district authorities and other organisations working in the districts, to avoid duplication of efforts. Food insecure TAs were given priority, on the basis that these communities have fewer resources to care for the chronically ill.

Beneficiary enrolment criteria at household level included food insecure households that had limited or no source of income, and income within the lowest community category. Also identified by the community or community organisation as in need of food assistance were:

• Households caring for a chronically ill or bedridden patient (where chronically ill shall mean illness for one month or more).
• Households caring for a patient on DOT
• Pregnant or lactating mothers under the PMTCT programme and their babies
• Households caring for orphans with special attention to elderly, child or single headed households hosting a large number of orphans (as defined by the community).

The monthly food basket for those on the HIV/AIDS programme is 10kg of corn soya blend/vegetable oil for the chronically ill, and 50kg of maize, 5kg of pulses and 3.7kg of vegetable oil for households with CI or orphans.

Targeting took place through existing community structures, such as Village Action Committees (VAC), Orphan Day Care Centres or other Community Based Organisations (CBOs) for the chronically ill or bedridden, and orphans. Targeting was also advocated through institutions such as hospitals or clinics for TB patients on DOT and pregnant or lactating mothers under PMTCT and their babies.

Establishing the targeting process involved a number of steps. Sensitisation meetings were held at TA and village level to introduce the programme, discuss targeting criteria, and select or introduce an existing committee. Orientation of committee members on their roles and responsibilities and identification and registration of beneficiary households followed. Verification of beneficiaries by NGOs in collaboration with the community or community organisations was conducted through community meetings or household visits.

Revision of guidelines

In light of experience gained during EMOP 10290, including analysis of Post Distribution Monitoring and Community Household Surveillance data² and an evaluation conducted in April /May 2004 (Salephera Consulting LTD 2004), these guidelines were revised for the subsequent PRRO (JEFAP 111). Key findings in the 'Salephera' evaluation were that guidelines on targeting chronically ill and orphans were followed in almost all areas visited. However, difficulties implementing the guidelines arose since there were more vulnerable people in the communities than the number actually covered by the programme. Community perception of the most vulnerable for food aid has included people who are not most vulnerable as defined in the guidelines, and there has been limited community involvement, sensitisation and verification during beneficiary targeting and selection. As a result, conflicts sometimes developed between those responsible for food distribution, beneficiaries, and those that believed they should qualify for food aid but were excluded.

The new JEFAP 111 guidelines have, therefore, strengthened guidance on community sensitisation, selection of committee members, development of community defined selection criteria, beneficiary selection and verification. It also made certain substantive changes with regard to how to target.

Programme observations

A number of observations were made, based on interviews with WFP staff and four site visits.

In the sites visited, those beneficiary chronically ill and orphan containing households interviewed were acutely food insecure and deserving of support.

Although the programme for the CI and orphan containing households should be integrated with otherHIVservices (see JEFAP 11and111 guidelines³), this is often not feasible. Hence, many beneficiaries of the CI and orphan programme receive food aid but no other resource or form of support. Households and Village Relief Committee's (VRCS) prioritised the need for drugs for these individuals to complement food provision.

The ration provided for households with orphans was the same, irrespective of the number of orphans. Households selected with orphans tended to have multiple orphans, with an average of three.

None of the chronically ill or orphan containing households interviewed were aware of exit criteria, other than when the EMOP ended. It appears that, to date, there has been no graduation due to improved food security of the chronically ill or orphan containing households.

Most beneficiaries (individuals or households) indicated that there were many others chronically ill or households with orphans who were not enrolled on the programme but were equally needy. In a country where an estimated 65% of the population live below the poverty line and there is an HIV prevalence of 14.4%, this is unsurprising.

Out of those presenting for selection for the PRRO starting in January 2005, the number/proportion of households per village selected was small/low (in some cases, each village was only able to select five households).

Ensuring that food commodities are delivered close to where beneficiaries live poses a considerable challenge of loading small tonnages for various locations, which is not cost-effective.

Conclusions

Donor environment and availability of resources

The current donor environment in the Southern African region is, at best, sceptical and, at worst, negative, with regard to the potential role of food aid in supporting PLWHA- especially in non-emergency contexts. There are emerging views that such households and individuals urgently require medical intervention and safety net programmes as a priority, rather than food aid. The result has been the type of situation seen in Malawi, where scarce resources from donors have to be targeted to a very small percentage of those in need, creating enormous pressures on WFP, implementing NGOs and communities.

However, food aid may well prove to be an integral component of what PLWHA require. There is emerging evidence that certain nutrients may halt progress of the disease, and adequate diet is essential for maximising the impact of ARVs. Food aid may assist compliance with treatment (ARV, DOT) and participation in programmes (such as PMTCT). Food aid may also be an important vehicle to allow acquisition of skills and community resources which promote longer-term food security amongst PLWHA.

Yet, before such such programming can be fully supported and rolled out on a national scale, there needs to be proof that objectives can be met. Longer survival times, less morbidity, improved nutritional status and attainment of longer-term food security need to be proven. Objectives of programming need to be clearly articulated and credible monitoring established to show whether these impacts are achievable and what the role of food is in meeting these objectives. Perhaps key to proving a role for food aid is the axiomatic truth that food aid can only have a significant impact if well integrated with other services, including health care (for example, drugs for opportunistic infection and where possible, rolling out of ARVs), health and nutrition education, psycho-social support, provision of adequate water and sanitation, etc). The institutional complexities of providing integrated programming in a country like Malawi is, however, poorly understood, both in terms of 'how to make it happen' and resources needed.

Rolling out a national programme before there is evidence that objectives can be met within an integrated programming environment, and how to realise this environment, may set back a realistic appraisal of the potential role for food aid in supporting PLWHA.

Targeting

It is extremely difficult to evaluate the success of targeting under the HIV/AIDS programme in Malawi and other countries in the region. While the Post Distribution Monitoring (PDM) examines inclusion and exclusion with regard to social and economic criteria, it is unable to do this with regard to HIV infection as there is limited HIV testing in Malawi. While targeting through DOT, ARV, PMTCT and HBC programmes can be assumed to result in high targeting efficiency with regard to HIV/AIDS infected individuals (over 70% of TB cases in Malawi are known to be HIV positive), targeting on the basis of chronic illness or having orphans in a household may be an extremely imprecise way of providing food security support targeted at the most vulnerable PLWHA.

Although the JEFAP guidelines go some way to addressing the above concerns in deriving and advocating complementary indicators for inclusion, e.g. economic indicators, there is clearly significant room for inclusion and exclusion error with respect to the chronically ill HIV affected and those households whose food security has been critically undermined by HIV/AIDS.

A recent study⁴ by AAH in Malawi drew the following conclusions regarding targeting vulnerable households within the context of HIV/AIDS;

• Is it a greater priority to improve the selection of the more vulnerable households within Malawi's context of chronic poverty, whether the vulnerability is rooted in HIV/AIDS or not? For methodologies intended to target food security input interventions, the degree of household vulnerability should take precedence over the cause of that vulnerability during beneficiary selection and should avoid reliance on simple proxies.
• Popular proxies used to detect vulnerable and/or HIV/AIDS infected/affected house holds, while theoretically indicative, are often practically imprecise with regard to identifying vulnerable households. Other proxies, such as the household food requirement:labour dependency ratio, should be piloted and developed.

Recommendations

Pregnant or lactating mothers may be targeted with food aid

Targeting food aid support to PMTC/ARV /DOT individuals is an efficient means of providing nutritional support to the HIV infected. However, although consensus regarding the differential nutritional requirements and rations for those infected with HIV has not been reached, there is some agreement on the need for differential rations according to stage of disease. For example, it is believed that a 10% increase in energy intake is required to maintain nutritional status and avoid weight loss of asymptomatic individuals living with HIV, while those with AIDS related illnesses require a minimum of 20% increase in energy intake, with as much as 50% higher protein requirements. WFP will need to monitor emerging consensus on this subject and adjust rations accordingly. At the same time, implementing ration differentials will be extremely challenging from a logistical perspective.

There is an urgent need to pilot integrated programming in one or two districts. These pilots should set clear objectives (nutritional, health and food security) and establish rigorous monitoring. Such piloting was initiated in the WFP country programme before the emergency, but ceased with the advent of the EMOP 10200 as other more pressing needs took priority. WFP should also document the process and lessons learnt regarding how to establish integrated programming and the costs and expertise required to bring this about. If the findings are positive, then donor organisations may be more supportive of this type of programming with positive implications for resources and future targeting.

If the decision is taken to continue with targeting on the basis of CI and orphan containing households, then this should only be implemented where fully integrated programming can be guaranteed, i.e. it is combined with health service provision and effective and proven food security support initiatives. Future programming should, therefore, be based on a mapping exercise to determine where integrated programming can be guaranteed. This will lead to an overall smaller programme but should also make it possible to target food resources effectively. Furthermore, committees at those sites selected will not be required to make 'difficult and politically sensitive' household targeting decisions, as all CI and orphan containing households can be included. This type of 'integrated and targeted' programme would also substantially reduce logistical costs on a per tonnage basis.

Simultaneously, there is a need for pilot studies to test the targeting efficacy of using proxies such as CI. Thus, a pilot study checking the serum status of the CI would be valuable, recognising that such a study poses substantial ethical and practical difficulties.

For further information, contact Jeremy Shoham, ENN, email: jshoham@easynet.co.uk

¹Joint Emergency Food Aid Programme

²See evaluation in this issue of Field Exchange

³For JEFAP guidelines, contact ALNAP, ALNAP Secretariat, ODI, 111 Westminster Bridge Road, London SE1 7JD, UK Tel: + 44 (0)20 7922 0300, Fax: + 44 (0)20 7922 0399, Email: alnap@odi.org.uk or visit the weblink: http://www.alnap.org/pubs/pdfs/JEFAP_manual.pdf

⁴Munk M and Fisher N (2004). Targeting vulnerable house holds within the context of HIV/AIDS. An evaluation of a piloted methodology. Ntchisi, Malawi. Action Against Hunger. See summary in this issue of Field Exchange.