REACH OUT food assistance in Uganda

By Peter Paul Igu, Reach Out and Mary Corbett, ENN

Peter Paul Igu has been a full-time volunteer with the organisation, Reach Out, since Jan 2002, and is the food programme co-ordinator in Uganda.

The authors would like to acknowledge the work and appreciate the support of Dr Margrethe Juncker, the WFP and the Reach Out medical programme staff in Uganda.

Clients and staff receiving lunch outside the Reach Out clinc

Kampala, the capital of Uganda, hosts a population of around 1.5 million people. Located close to the shore of Lake Victoria, the city is built on a number of hills, giving it a somewhat unplanned, scattered appearance. The infrastructure struggles with the expanding population, leading to major congestion on the roads and, in areas where electricity is available, frequent interruptions in power supply due to ever increasing demands.

Mbuya parish is situated a few kilometres from the city centre. Based on the work of a number of small Christian communities, 'Reach Out' was established in the parish in May 2001, to support people living with HIV/AIDS (PLWHA) and their families. Initially, Reach Out activities mainly involved visiting chronically ill persons in their homes. Then, in January 2002, a clinic at Our Lady of Africa Church was established and over the last three years, has grown to become a vibrant organisation, providing families of PLWHAwith a holistic support mechanism. Dr Margrethe Juncker, one of the founding members, works tirelessly in the care and support of all the beneficiaries, and her energies have been instrumental in the growth of this project.

Reach Out activities

Reach Out operates the clinic four days a week. On the fifth day, patients are visited in their homes and training is conducted. Clinic activities include counselling and testing for HIV/AIDS (same day results, to reduce defaulting), clinical examination, and medical support for opportunistic infections. TB treatment and antiretroviral (ARV) support are part of the service. People can also meet with a micro-finance team and receive loans for business plans.

The project expanded substantially in 2004, with client numbers up by 68.8%, from 860 clients at end of Dec 2003, to 1452 by the end of 2004. During 2004, a total of 140 clients died, 22% within the first month of admission onto the project, 42% within the first 3 months, and over 60% within the first 6 months. These figures suggest many people come for help very late and are already extremely ill. Efforts are being made at a community level to encourage people to attend for testing earlier. Given the actual figures enrolled, it is thought that people are moving into the area so as to benefit from the services of this programme.

Medical care

In March 2004, Reach Out were recognised by the National TB programme and since then, a total of 464 patients have been enrolled in the TB programme. Free ARV treatment is also available for HIV positive clients with a CD4 count of <250. At the end of 2004, a total of 545 clients were receiving free ARV therapy. In order to support compliance for both TB and ARV treatment, a community network has been established to support people, with enrolees supporting one another. The team consists of two full time doctors, 12 nurses (one is involved in counselling), additional counsellors, and 230 volunteers - 77% of the volunteers are clients living with HIV/AIDs who, in turn, support new clients.

Nutrition support

Nutritional support, in the form of WFP food aid, commenced in June 2002, initially through AVSI¹ (implementing partner), and later, through a direct agreement (MOU) between Reach Out and WFP. Since then, the numbers of people receiving food assistance has substantially increased from around 600 to 1,000 beneficiaries. Reach Out has also acquired two containers to store a quantity of food, which assists in better planning of food distributions. Atotal of 10 food monitors, an assistant and a clerk support this project. The daily food assistance ration consists of 200g maize, 60g pulses, 20g oil and 100g corn soya blend (CSB), per person per day.

Admission criteria

New clients admitted to Reach Out are assessed on the day of admission. In the event that the client is seriously 'food-stressed', they receive an emergency food ration. Following on from this, the Food Assistance team visit the client in their home. They ensure the client is living in the locality and complete a WFP socio-economic survey questionnaire, which collects information on family size, foods eaten and meal frequency during the week. It also collects information on monthly income, source of income, and valuable assets owned by the household (HH). Based on this questionnaire, a decision is taken regarding eligibility for the food assistance project. Priority is now given to people on TB and/or ARV treatment. At present, around one thousand beneficiaries are receiving food assistance on a monthly basis.

Weekly Reach Out meeting held in a local church

Exit criteria

At present there are no exit criteria, with the exception of beneficiaries that default for a number of months. This sometimes happens when people move out of the area, possibly to move back home to family. Normally three months of default leads to removal from the project.

Monitoring

At each clinic visit, all clients are weighed by a nurse/doctor and have counselling if necessary. Initially when clients are registered in the programme, they are encouraged to attend the clinic on a weekly basis, then fortnightly and, once stable, monthly. Monthly information is collected on all beneficiaries on the food assistance programme. Table 1 shows summary data from August 2004, based on WFP monthly reporting.

During August 2004, 56.7% of beneficiaries gained weight, 28.9% lost weight, and 14.4% had static weight. Table 1 further profiles those who had lost/had static weights according to treatment /infection.

Plans regarding targeting

At the end of 2004, the WFP implementing partners (IP) convened to review the present programme. A small working group was set up to consider admission criteria. Existing questionnaires used by different IP's were reviewed and a new questionnaire has just been completed and will be piloted in March 2005. This questionnaire has a 'score weighting system' which it is hoped will facilitate targeting of the most vulnerable members in a programme and reduce subjective decision-making. Instead of a cut-off based on the amount of food available, the cutoff will be based on the scoring system, which is based on a more comprehensive economic status appraisal.

However, as yet, no exit criteria have been developed. In general, beneficiaries are informed that the food assistance will cease at some stage, although, so far, some beneficiaries have been on food assistance for 2.5 years.

Income generating activities (IGA)

IGAs take a number of forms, the largest being the 'Bread for Life' micro finance programme. This activity has seen a four-fold increase from 154 loans in 2003, to 650 loans in 2004. Clients must submit a business plan before a loan is sanctioned by the committee. The size of the loans has increased, now up to 100,000 Ush ($60) and repayment takes place over a six month period. The average recollection of loans is 81%. In general, 75% pay well, 15% are slow payers and a further 10% don't pay. The main activities in business plans include vegetable purchase and sale, stone quarrying, fish shelling, purchase and sale of second hand clothes, hair dressing and brewing. Clients may receive new loans once the old one has been paid off. Clients need to be registered in the programme for at least three months and attending clinics regularly before loans will be sanctioned.

Conclusions

It is felt that most people who attend Reach Out are poor or very poor. Initially there was some stigma around food assistance but after some time, it appears that food acted as an incentive for people to come to be tested for HIV/AIDS and receive assistance. For TB patients, in particular, once on medication, appetite increases and food assistance becomes essential to support well-being and compliance. Also, staff feel that TB patients are now recovering much better since the introduction of food assistance, and describe how "less TB patients were dying". Similarly, it is considered essential for clients on ARVs to receive food assistance so that their general condition improves. A one year time frame for food assistance to clients on ARVs may be introduced, which, it is felt, should be flexible.

Reach Out has a significant amount of data collected on clients over the years, i.e. weight trends, morbidity and mortality rates. Unfortunately, due to the enormous workload of day-to-day project implementation, it has been impossible to analyse these data. Project staff would welcome both technical and financial support in order to make use of these data, which could be invaluable in answering some of the key questions around HIV/AIDS and nutrition support/food security.

The volunteers in the programme, many of whom are HIV positive themselves, are inspirational in their positive attitude to life and their illness. In conjunction with the enormous commitment from other staff, this is probably one of the major factors contributing to the success of this programme.

For further information, contact Peter Paul Igu, P.O. box 6562 Kampala, Uganda. email: Igupeter@yahoo.com, tel (Uganda) 077-343027

¹Associazione Volontari per il Servizio Internazionale