Integrated Approach to Supporting Chronically Ill in Malawi

Interview by Mary Corbett with Mrs Nellie Nyang'wa, Oxfam

For the past three years, Nellie Nyang'wa has been the Country Programme Manager for Oxfam in Malawi. Her previous work includes 2.5 years in development grants management (Oxfam), and 6 years in microfinance (World Vision International). She is also Vice Chairperson of the NGO Board of Malawi.

This article describes the evolution of Oxfam's operations in Malawi, and touches on how Oxfam have been influenced by their regional experience of HIV/AIDS.

Evolution of Oxfam's approach

Prior to 1996, Oxfam provided financial support from their Zambia based operation to a mixture of partner implemented programmes in Malawi. In 1996, Oxfam became physically operational in Malawi, embarking on direct programming as well as working through partners, and focusing on livelihood support. Key activities included onfarm production, off-farm production, supporting small businesses, and social mobilisation in the form of capacity building. In 1999, the programme approach changed within the Oxfam global organisation, with the focus more on strategies to change the lives of the poor. Consequently, this meant a shift towards policy and practice changes that impact on poverty. Within this broader programme framework, the Malawi country programme focused on food and income security for the poor, their right to be heard, and gender. In 2000, in response to a greater awareness of the impact that HIV/AIDS was having on communities they were working with, Oxfam Malawi changed strategy again, this time mainstreaming HIV/AIDS work in all their programmes.

Tending to a household vegetable plot

Following on from the 2002 food crisis, there was a realisation that the effect of the countrywide food insecurity was particularly marked for those households affected by HIV/AIDS. In 2003, Oxfam decided that a new strategy was required specifically to deal with this problem since despite reaching the end of the drought assistance period, it was felt "it was not possible to pull out as people were too vulnerable". This article outlines this new programming strategy for Oxfam in Malawi.

Rationale of current approach

Underpinning the new strategy was the Oxfam Malawi team's feeling that food aid was essential, in the short term, to save lives. Without food aid, very sick people will not survive. Bridging the gap is also critical in order to support more long-term food security through strengthening food production. Food aid can break the cycle leading to individual and household crisis. However, strengthening food production to bolster longer-term food security is particularly challenging in Malawi, where agriculture is rain-fed and therefore highly dependent on rainfall and drought.

The need to support seriously ill patients with health care and medications is clearly a priority. Prescribing medicines on an empty stomach is not advisable and can influence tolerance to medication. Therefore it is important to have both a food aid component and more long-term food security measures to support patients' health.

In order to have a significant impact, these considerations argued for an integrated approach to programming for the chronically ill and their families through provision of health care, meeting immediate food needs, and long-term food security initiatives.

Given the vulnerability of the chronically ill, an integrated approach to interventions was developed by Oxfam which encompassed;

• Safety nets support in the form of food aid and free inputs.
• Medications and health care with advocacy as a key strategy.
• Support to longterm food security.

Population

Oxfam is operational in three rural districts, Mulanje, Thyolo and Phalombe, in the southern region of Malawi. The government is a key partner in all three districts, as are a number of NGOs. According to the 1998 population census, the population of Thyolo is 458,976 and that of Mulanje is 428,322. The 2001 integrated household survey showed that 71% of Thyolo and 60% of Mulanje populations lived in poverty. In Mulanje, Oxfam is targeting half the villages in the district while, in Thyolo, fewer villages are yet involved as it is a relatively new district for the programme. Since MSF-Luxembourg (MSF-L) is also operational in Thyolo, a working relationship has been developed to avoid duplication and ensure comprehensive support to the communities.

Targeting

All interventions are targeted through structures within the communities, mainly Village Development Committes (VDCs). For the safety nets and healthcare programmes, Oxfam works with home based care (HBC) structures, where these exist, and where there are no HBCs, with VDCs at a community level. Through the HBC structure, beneficiaries are identified, prioritising the worse affected. Food aid and care support is given, and longterm food security support is mobilised and supported. Beneficiary status is reviewed on a monthly basis.

Programme

At present, 3,500 households (HH) are receiving food aid from Oxfam, while an additional 5,228 HH are receiving food aid from WFP. Afamily basket of maize 50kg, oil, beans and Lukini Phala¹ are given on a monthly basis. This element of the programme comprises approximately 10% of the programme budget.

Oxfam recognises that there is a need to stimulate household and community production. At present this is taking place through training, distribution of seeds for communal gardens, distribution of fertiliser and development of village grain banks linking production to vulnerable households.

Health care is conducted through the HBC structure. In Thyolo, a Memorandum of Understanding with MSF-L is being signed to link programmes and prevent overlap. MSF has the capacity to test and treat tuberculosis (TB), have facilities for VCT (voluntary counselling and testing), and have the capacity to support patients with antiretroviral therapy. With good collaboration it is hoped that Oxfam will mobilise people to access MSF services, while supporting food security initiatives for these individuals.

Challenges

There are a number of challenges for this programme. Food insecurity in the region is a longterm problem, and food aid is a costly and not sustainable long-term measure.

The challenges faced are a composite of addressing immediate needs and longer-term food security. However, without addressing both concurrently, it would be very difficult to make substantial progress. Although food aid has been very well received and appreciated, it is difficult to measure impact of this intervention. There is a need to develop tools to measure impact of this integrated approach.

Access to markets is a major constraint, and it may be necessary to consider 'fair trade' issues while attempting to strengthen markets. Also, linkages between HBC and the health infrastructure are very weak. While HIV/AIDS related needs will remain for many years, strengthening community mechanisms may help to ensure longer-term support for the chronically ill.

Future plans

In 2006, Oxfam plans to expand its present programme and work in another district, (likely Blantyre Rural) using the same approach with an expanded budget. Oxfam also plans to strengthen their work in the key areas of advocacy, emergency preparedness and mitigation and capacity building within the Ministry of Health.

For further information, contact Oxfam Malawi, P/B 213, Blantyre, Malawi.

¹A locally produced fortified blended food