DAPPœTCE Programme Evaluation
May/June 2008
Development Policy & Practice Authors: Jerry Mameja, NEDICO and Pam Baatsen, KIT
September 29, 2008
Development Policy & Practice, Amsterdam September 29, 2008
Mauritskade 63 1092 AD Amsterdam Telephone +31 (0)20 568 8711 Fax +31 (0)20 568 8444 www.kit.nl Acknowledgements
We would like to thank all those who generously took time to be interviewed, to answer questions, to share their views and, in many other ways, to make certain that we had the information required to complete this study.
Our gratitude goes, first and foremost to all DAPP staff, the Director, Corps Commander, Deputy Corps Commanders, Division Commanders and Field Officers, who greatly facilitated our stay and tirelessly shared their visions and experiences. Your active collaboration, openness and keen interest in the evaluation has made this evaluation possible.
Furthermore, we are grateful to all the men and women in the field who opened their houses so that we could observe the door-to-door approach in action and who very engagingly answered our long list of questions.
We also greatly appreciate the time dedicated by regional and local representatives, ranging from governors, councillors, traditional leaders, NGO representatives and health workers, to share their perspectives on the TCE programme. We would also like to thank CDC Namibia for the collaboration received.
Lastly, we would like to express our gratitude to the Global Fund PMU and MoHSS for the support provided.
We hope we have adequately reflected the information collected in the field and that the evaluation findings and recommendations contained in this report will contribute to the further strengthening of TCE programme.
i ii Abbreviations
ARV Anti Retro-Viral CC Corps Commander DAPP Development Aid From People to People DC Division Commander DDC Deputy Division Commander DI Development Instructor FO Field Officer GF Global Fund GFATM Global Fund for AIDS, TB and Malaria MoHSS Ministry of Health and Social Services MSM Men Having Sex with Men PES Perpendicular Estimate System PL Patrol Leader PLHIV Person living with HIV PMTCT Prevention of Mother to Child Transmission SF Special Force STI Sexually Transmitted Infections TC Troop Commander TCE Total Control of the Epidemic TOR Terms of Reference VCT Voluntary Counselling and Testing
iii
iv Executive Summary
The Total Control of the Epidemic (TCE) programme was developed by Humana People to People of which DAPP Namibia is a member and co-founder. The overall aim of the programme is to fight HIV in Southern Arica. The first programme was implemented in Zimbabwe in 2000, and since then the programme has been expanded to Botswana, Namibia, South Africa, Mozambique, Angola, Zambia, and Malawi. In each of these countries DAPP aims to mobilize both individuals and the community to take control of the HIV epidemic through a face-to-face approach during a three-year campaign. The approach includes dividing (part of) a country in TCE areas consisting of 100,000 people each. For each TCE area, 50 people from the area are recruited and trained as TCE Field Officers. All Field Officers are expected to cover 2,000 people or approximately 350 household through a door-to-door approach. The Namibian version of the programme officially started in Mid 2005 in Omusati, Oshana, and part of Ohangwena and Oshikoto, with support from the Namibian Round 2 Global Fund for AIDS, TB and Malaria (GFATM) received from the Ministry of Health and Social Services (MoHSS). The programme was further expanded in 2006/7/8 to cover the remaining constituencies in Ohangwena and Oshikoto, as well as Kavango, Caprivi and part of Khomas regions. This expansion was supported by CDC Namibia and therefore not covered by this evaluation. CDC is planning a mid-term review of these areas in the near future.
The first five TCE areas supported by the GFATM are scheduled to phase out in August 2008, while the last GFATM supported area is phasing out in December 2008, hence the MoHSS/GFATM‘s call for this end of project evaluation. The evaluation reviewed the effectiveness and efficiency of the TCE campaign which has reached close to 700,000 individuals through door-to-door visits. The evaluation further reviewed whether the Namibia Global Fund programme should renew its support for the DAPP TCE programme and if so, in what way.
This evaluation was carried out by the New Dimensions Consultancy (NEDICO) and the Royal Tropical Institute (KIT) Consortium. The Consortium has been providing managerial and technical support to the Namibia GFATM Programme since late 2004. The evaluation team consisted of one member from NEDICO and another from KIT. The team developed and used a number of tools and techniques to collect qualitative information from (traditional) community leaders, TCE staff, TCE Passionates, household members, health workers, and other stakeholders such as New Start staff and staff from the Namibian Red Cross Society.
The evaluation team found that the TCE programme has made significant inroads into all the communities it operated in and that the acceptance level of the programme is remarkable. Every individual we spoke to commended the door-to-door approach of TCE. Furthermore, they all felt strongly that the programme should be continued until all people are reached. The monitoring data also showed that at this moment considerable numbers of new people are being registered every week; mostly due to high levels of migration. Respondents also indicated that many men have not yet been reached and that it usually takes more time for men to be brought on board.
Key recommendations outlined at the end of this evaluation include that the TCE programme should be continued for two more years in the geographic areas currently being covered, which are in fact the most densely populated areas of Namibia. During those two years efforts should be geared towards reaching out to those not yet reached. A second key recommendation is that
v the communication/facilitation skills of Field Officers should be strengthened so that they can also start addressing drivers of the epidemic, such as multiple concurrent partnerships, transactional sex, intergenerational sex, alcohol use, MSM, traditional practices such as drying of the vagina and male circumcision, more effectively. The evaluation team is of the opinion that this will allow the programme to be taken to the next level in which it works towards reducing new HIV infections. Lastly, the evaluators also believe that it would be appropriate and useful to expand the TCE face-to-face approach to other regions in Namibia.
vi Table of contents
Acknowledgements...... i
Abbreviations...... iii
Executive Summary...... v
1 Introduction and background...... 1
2 Objectives...... 3
3 Methodology...... 4
4 Limitations...... 5
5 Findings and Conclusions...... 6 5.1 Management and organization...... 6 5.1.1 Staffing and management structure...... 6 5.1.2 Acceptance of FOs by communities ...... 9 5.1.3 Internal meetings...... 9 5.1.4 Staff turn over...... 10 5.1.5 Finances ...... 11 5.1.6 Monitoring and evaluation...... 11 5.1.7 Conclusions ...... 11 5.2 Approaches ...... 12 5.2.1 Door-to-door approach...... 12 5.2.2 Number of people still being registered (first time contacts) in 2008 .... 13 5.2.3 Peer Support Groups...... 14 5.2.4 Vulnerable groups ...... 14 5.2.5 Conclusions ...... 14 5.3 Tools used for TCE Implementation...... 15 5.3.1 Tools for door-to-door outreach...... 15 5.3.2 TCE Compliant...... 15 5.3.3 Conclusion...... 16 5.4 Capacity Development and supervision...... 16 5.4.1 Training of staff...... 16 5.4.2 Quality assurance/support to FOs ...... 17 5.4.3 Skills mix of FOs ...... 17 5.4.4 Training modules...... 17 5.4.5 Conclusions ...... 18 5.5 Effectiveness of the interventions and changes observed...... 18 5.5.1 Role modelling œ knowing your status and being open about it...... 18 5.5.2 Uptake VCT, ART, and PMTCT...... 19 5.5.3 Condom distribution and use...... 22 5.5.4 Stigma, discrimination and general perception of HIV...... 23 5.5.5 Addressing the drivers of the epidemic...... 24 5.5.6 Conclusions ...... 24 5.6 Evolvement of programme and next phase...... 25 5.6.1 Establishment and visibility in communities ...... 25 5.6.2 Passion for People Movement“ volunteers and FOs ...... 25 5.6.3 Referral/drawing upon other resources ...... 26 5.6.4 Ready to move to next phase?...... 26 5.6.5 Issues still to be œ systematically - addressed...... 27 5.6.6 Conclusion...... 29
vii 6 Recommendations...... 30 6.1 Management and organization...... 30 6.1.1 Staffing and management structure...... 30 6.1.2 Acceptance of FOs by community...... 30 6.1.3 Internal meetings...... 30 6.1.4 Staff turn over...... 30 6.1.5 Finances ...... 30 6.1.6 Monitoring and evaluation...... 30 6.2 Approaches ...... 31 6.2.1 Door-to-door approach...... 31 6.2.2 Number of people still being registered (first time contacts) in 2008 .... 31 6.2.3 Peer Support Groups...... 31 6.2.4 Vulnerable groups ...... 31 6.3 Tools used...... 31 6.3.1 Tools for door-to-door outreach...... 31 6.3.2 TCE Compliant...... 32 6.4 Capacity Development and supervision...... 32 6.4.1 Training of staff...... 32 6.5 Quality assurance/support to FOs ...... 32 6.5.1 Skills mix of FOs ...... 32 6.5.2 Training modules...... 32 6.6 Effectiveness of the interventions and changes observed...... 32 6.6.1 Role modelling œ knowing your status and being open about it...... 32 6.6.2 Uptake VCT, ART, and PMTCT...... 33 6.6.3 Condom distribution and use...... 33 6.6.4 Stigma, discrimination and general perception of HIV...... 33 6.7 Evolvement of programme and next phase...... 33 6.7.1 Establishment and visibility in communities ...... 33 6.7.2 Passion for People Movement“ volunteers and FOs ...... 34 6.7.3 Referral/drawing upon other resources ...... 34 6.7.4 Ready to move to next phase?...... 34 6.7.5 Issues still to be addressed:...... 34
ANNEXES...... 37 Annex A: DAPP œ TCE Programme Evaluation Schedule...... 39 ANNEX B: List of documents reviewed ...... 43 Annex C: Data Collection Instrument...... 44 Annex D: TOR for the Evaluation of DAPP TCE programme...... 48
Chart DAPP Organisational chart...... 8
Graphs Graph 1: HIV Prevalence among pregnant women by Year of Survey...... 1
Tables Table 1: VCT clients in the period 2005 œ 2008 ...... 20 Table 2: HIV prevalence ratios by site for the years 1992 œ 2006 ...... 21
5/Dev/08.105/PB/ag September 2008, 558 703
viii 1 Introduction and background
Namibia ranks high among the countries most affected by HIV in the world. Available data from the 2006 HIV Sentinel Surveillance data indicate that nearly one out of every five pregnant women was infected with HIV.. Although large regional variation was found, ranging from one out of 12 women (7.9%) in one region to one out of two/three (39.4%) women in another region.
Graph 1: HIV Prevalence among pregnant women by Year of Survey
25 22 19.3 19.7 19.9 e 17.4 c 20 n
e 15.4 l
a 15 v
e 8.4 r P
10 V I H 5 4.2 % 0 1992 1994 1996 1998 2000 2002 2004 2006 Year of Survey
Source: Report of the 2006 National HIV Sentinel Survey, MoHSS, 2007
HIV has affected and continues to affect large numbers of individuals, families and communities in Namibia. The pandemic has created a severe burden for the country in terms of social and economic costs, cutting across all facets of the society including the health system as more and more people fall sick, including health workers, with increased demand for ARV treatment. Considerable efforts to reverse the epidemic and mitigate its impact have been undertaken. However, prevention efforts, as can be seen from the graph above, have so far not yielded the expected results. It is against this background that DAPP started to develop its Total Control of the Epidemic (TCE) programme in 2004/2005 in Namibia.
Project description and objectives The TCE programme approach was developed by Humana People to People to fight HIV in Southern Africa. DAPP is a member and co-founder of Humana People to People. The first TCE programme was implemented in Zimbabwe in 2000, and since then the programme has been expanded to Botswana, Namibia, South Africa, Mozambique, Angola, Zambia and Malawi. In each of these countries DAPP aims to mobilize individuals and the community to take control of the epidemic through a face-to-face approach during a three-year campaign. This is done by dividing (part of) a country in TCE areas consisting of 100,000 people each. For each TCE area, 50 people from the area itself are recruited and trained as TCE Field Officers. All Field Officers are expected to cover 2,000 people (one-by-one) or approximately 350 household through a door-to-door approach within a three-year time frame (DAPP-TCE Namibia Field Officer Initial Training Manual).
The TCE programmes work closely with government health institutions such as hospitals and clinics, VCT centres, traditional leaders, regional and local administrators (governors, councillors) from the start up of the programme and throughout its implementation phase.
DAPPœTCE Programme Evaluation | May/June 2008 1
The objectives of the TCE project for Namibia are: • To mobilize area by area , educate and organize people to gain control of HIV • To improve knowledge and attitudes, and change behaviour related to HIV through increased cooperation in IEC activities • To develop IEC materials suitable for all media formats and disseminate to young people, including youth with special needs. • To increase the number of sexually active individuals using condoms (male and female) • To increase the number of people who go for VCT through mobilisation and counselling
The strategies to achieve these objectives are: • To adopt the TCE systematic approach of reaching every single person with counselling for behaviour change • To organise the communities into TCE areas and fields to ensure that every single person is mobilized to take control of the epidemic • To organise people in the —Passion for People Movement“ to volunteer and form groups to assist those who are infected and affected by the epidemic
In Namibia the programme officially started in Mid 2005 in Omusati (all constituencies), Oshana (all constituencies), Ohangwena (5 constituencies) and Oshikoto (6 constituencies) with support from the MoHSS/Global Fund. The programme was expanded in 2006/7 to cover the remaining 6 constituencies in Ohangwena and the remaining 4 constituencies in Oshikoto, as well as Kavango. This expansion was supported by CDC Namibia, who also provided funding in 2007/8 for further expansion to include Caprivi and Khomas (Windhoek) region.
Evaluation The DAPP TCE three year campaign supported by the MoHSS/Global Fund in Omusati, Oshana, Ohangwena and Oshikoto regions in Namibia is coming to an end. The first TCE areas are scheduled to phase out in August 2008.
MoHSS/Global Fund have called for an end of project evaluation to assess the effectiveness and efficiency of the TCE campaign which has reached close to 700,000 individuals through door-to-door visits. The evaluation also intends to provide insight as to whether donor funding for these and possibly other regions should continue and if so, whether programme objectives, policies and implementation strategies need adjustment.
The evaluation has been limited to the DAPP TCE activities funded by the Global Fund. The TCE activities supported by CDC Namibia have therefore not been included. However, CDC has scheduled a mid-term review in June/July 2008.
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2 Objectives
The evaluation aims to answer the following questions: • How effective and efficient have the implementation strategies of the TCE programme been to reach its objectives? • How many people have been reached through which activity and what has been the frequency of the interaction with the different activities? • Has the programme provided individuals, households and/or communities with knowledge, skills, motivation and the enabling environment necessary for increased care and treatment seeking behaviour as well as reducing the risks of HIV transmission? • Has the Programme resulted in increased care and treatment seeking behaviour and reduced HIV transmission risk? • How sustainable is what has been put in place by the programme? Is the programme ready to evolve to the next phase where the door-to-door approach of reaching all individuals is replaced by a targeted approach for a selected group of individuals?
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3 Methodology
The two member evaluation team used the following approach:
In line with the Terms of Reference, the evaluation team developed a work plan (see annex A). This work plan was then discussed with the DAPP management and the Programme Management Unit (PMU), managing the GF resources for MoHSS in Windhoek. The team travelled from Windhoek to Ongwediva from where they visited the Omusati, Oshana, Ohangwena and Oshikoto regions. The visits took place between May 23 and June 3, 2008. During the visits the evaluators interviewed a wide range of stakeholders and observed different activities.
Data collection tools were developed and used to conduct: • Focus Group Discussions with DAPP Field Officers/Management, individuals/households, PLHIV peer support groups reached by TCE and RACOC members. • In-dept interviews with key stake holders (Governors, traditional/community leaders, service providers, etc) and people reached by TCE and those not (previously) reached. • Role plays to review interaction of DAPP Field Officer Staff with individuals, household and communities. • Observation of door-to-door visits and a number of visits (troop meetings and Division Commander Coordination meeting). • Trend appraisal by households/group members to analyse changes over time (onset of TCE programme versus now). • Review of different programme reporting systems. • Review of training materials for DAPP staff. • Review of DHS/Sero surveillance, VCT, ARV, PMTCT data and reports disaggregated into TCE and non TCE areas.
The initially proposed additional data collection tools as the —Story with the Gap“, —case studies“ and —life skills“ activity were not used. The —Story with the Gap“ was dropped because no good pictures showcasing a —before“ and —after“ situation could be found. The case studies were dropped as the TCE Field Officers had already prepared a number of interesting case studies that could be used to illustrate the findings of the evaluation team. The Life Skills activity was dropped as we were not able to meet with a youth group because of the tight schedule.
The sites to be visited in Omusati, Oshana, Ohangwena and Oshikoto were decided upon in consultation with DAPP. Purposeful sampling was applied to ensure that the evaluators could visit a wide range of activities, talk to a diverse range of persons as possible and visit both rural and urban communities.
Different TCE staff members accompanied the evaluators. TCE Field Officers or Special Forces from the area helped with translation.
At the onset of the evaluation, a three hour workshop on basic evaluation skills, were provided by the evaluation team for key DAPP staff by taking them, through the steps of an evaluation process.
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4 Limitations
• Measuring outcome and impact: The existing tools for measuring outcome (Demographic Household Survey) and impact (National HIV Sentinel Surveillance) have severe limitations. While the TCE project started in mid 2005, data for the last Demographic Household Survey was collected in November 2006œ February 2007. This means that instead of measuring possible outcome after a three year campaign, the DHS can only measure behavioural change achieved between mid 2005 and the end of 2006. Similarly, the available data from the National HIV Sentinel Survey was collected from JuneœOctober 2006 and while a new round of surveillance is ongoing, these data are unfortunately not yet available. Besides, as the Sentinel Survey only focuses on pregnant women attending ante-natal clinics, this group may well not be representative for the rest of the population as they 1) are not using condoms consistently, 2) do not represent the male population and 3) sentinel sites tend to be biased towards urban settings (MoHSS, National TB and HIV Targets report). With the available outcome/impact evaluation tools it is therefore unfortunately not possible to measure any outcome, impact for the course of the project. • Translation: As the reviewers did not speak the local language, translation in the field was provided by DAPP staff. Sometimes it was hard for the staff to translate everything that was said. However, as one of the evaluators had basic understanding of the local langue, he would notice in such cases that information was missing and could request for a more comprehensive version of the translation. • Possible bias through TCE involvement: The fact that TCE was present at most, but not all of the interviews, may also have influenced the findings. Where they were present, TCE staff would only observe and or translate. Prior to the interview they encouraged the respondents to be frank and open and to share whatever they wanted. The evaluators noted that at the interviews where TCE staff was not present, the same kind of comments were made as in the interviews where TCE staff was present. • Selection of sites: The evaluators visited sites in all the regions covered by the Global Fund resources. However, the actual sites visited and the Field Officers accompanying us were selected by DAPP. For the selection, often practical reasons were used, like trying to avoid travelling too long to reach the area to be covered by the field officer. The sites visited may, therefore, not be fully representative. • Covering large distances: In spite of efforts to choose sites which were relatively near, large distances had to be covered as the programme covers two complete regions and half of two other regions. This meant that considerable time was spent driving. While most of the time in the car was used to obtain more information and discuss issues with people from the leadership unit accompanying the team, it also meant that less door-to-door visits could be observed than planned.
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5 Findings and Conclusions
The key findings have been clustered under the following headings:
1) Management and organization, 2) Approaches, 3) Tools used and qualifications, 4) Capacity development and supervision, 5) Effectiveness of the interventions at different levels and changes observed at outcome levels.
Within each of these areas, the evaluators have tried to look at relevance, effectiveness, efficiency, sustainability and impact.
5.1 Management and organization
5.1.1 Staffing and management structure The Field Officers (FOs) in TCE are the —foot soldiers“ of the programme. They are the ones interfacing with people and communities through door-to-door visits. Two hundred and ninety (290) FOs collectively cover the whole of Oshana and Omusatie and part of Ohangwena and Oshikoto regions with support from Global Fund resources.
A solid management structure has been put in place to manage, supervise and assist these FOs. This structure consists of a Corps level, which has the overall responsibility for the programme. Below are 4 Divisions that are headed by Division Commanders and one or two Deputy Division commanders. Each Division is in turn divided in troops consisting of around 50 Field Officers. These troops are headed by Troop Commanders. Each troop is divided into 5 patrols consisting of 10 Field Officers each. At all levels there are the Special Forces, within . the leadership unit, whose roles include monitoring and evaluation and training. At division and troop levels these Special Forces are responsible for organizing PLHIV support groups, ensuring equal division of work load, training, etc. For an overview of the management structure, please see the next page.
While the evaluators were impressed by how well the whole organizational structure seems to be functioning, and the very strong in-built supervisory mechanisms, the downside of the multi-layered management structure is that its makes the programme more expensive. For example, while for the first year US$ 360,000 was budgeted for employing the 290 FOs, approximately US$ 300,000 was budgeted for the salaries of the rest of the staff. For year two the ratio between FOs versus rest of the staff was US$ 360,000 versus US$ 260,000. This means that less than 60% of funds earmarked for staff salaries were used for those implementing the programme and more than 40% for those supervising the programme. However, as the programme has such a wide reach, the unit cost per person reached is approximately US$ 6 (Six United States Dollars). The evaluators realize that the programme employs Field Officers who in general have had very little education, which makes ongoing capacity building and on the job training essential. Motivation and monitoring of the FOs is also crucial as the FOs often face tough weather conditions, have to walk or cycle long distances, come across emotionally difficult situations and receive limited financial compensation in return. The management structure is well described with clearly defined roles, with the exception of the division of tasks between the Division Commanders and the
6 DAPPœTCE Programme Evaluation | May/June 2008
Deputy Division Commanders positions. There is however a manual guiding the Division Commander‘s work. The Division Commanders and Deputy Division Commanders work very closely together and coordinate tasks at hand. However, there is no clear upfront division of tasks between them and the job descriptions for those positions are therefore very similar. The Corps level handles economic control, book keeping, audit, reporting to partners and liaises with the national level. The Divisions focus on programme implementation and liaison with local level stakeholders, including RACOCs, CACOCS, clinics and traditional leaders.
DAPPœTCE Programme Evaluation | May/June 2008 7
Management & support positions DAPP Organizational Chart Implementation positions
Projects DAPP Director
DAPP Private school DAPP Vocational Coordinator (Corps Commander) Child AID & grade 1-10 school Environment Projects
GFATM Malaria TCE New Start VCT HOPE Humana Campaign in North Outapi Projects
Asst. Programme Asst. Logistics (Deputy Corps Commander) (Deputy Corps Commander) P.R. Officer SF Training Accountant & bookkeepers S.F. S.F. S.F.
Division Commander 1 Division Commander 2 Division Commander 3 Division Commander 4 Oshana/Omusati (Global Fund funded) Ohangwena/Oshikoto (GF & CDC) Kavango/Kaprivi (CDC funded) Khomas (CDC funded)
S.F Deputy Deputy Deputy Deputy Deputy Deputy Deputy (3)
TC1 TC2 TC3 TC4 Osh/Omuana Omusatiana Omusatiana Oshana TC1 TC2 TC3 TC4 TC1 TC2 TC3 TC1
50 FO 50 FO 50 FO 40 FO 50 FO 50 FO 30 FO 58 FO 68 FO 32 FO 40 FO 52 FO
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5.1.2 Acceptance of FOs by communities The selection of FOs was based on the following criteria: • Candidates had to be from the same community where they are going to work. This was checked with local administrators. • Candidates had to Changing lives of Field Officers have basic English FOs are encouraged to prepare case studies on how • Candidates had to their lives have changed as result of their work with have completed grade TCE. Below is an excerpt from a female Field Officer 10-12 who started as a TCE passionate (volunteer): • Candidates had to be
above 23 years of age —After I completed my grade 12 in 2002, I stayed at • Candidates had to home doing nothing, no further study and no job“. successfully pass the In February 2005 I decided to have a boy friend, I TCE basic training knew this boy had many girlfriend/partners, but I • Candidates had to did not hesitate. I wanted to be his also, so I went hand-over a letter of for him. Sometimes I used to sneak out of the house recommendation from and go to him. I used to drink alcohol before I joined a local leader TCE, my life was miserable. I did not care much
about my self. In September 2005, two ladies came Many of the FOs selected to our house talking about the TCE program, and had been unemployed for a they said, they needed passionates/volunteers to number of years and help them with many things such as working along were quite young. Initially with them…. One day, the Field Officer asked me if I some people doubted was tested for HIV: then I said no because I was whether the FOs would be afraid. He said that if you don‘t make the right accepted by the community. choice now, it will be too late. Round about October However, all stakeholders I decided to go for HIV test in the New Start Centre. interviewed mentioned that When I got tested in October 2005 I felt so proud they had seen the FOs and so courageous, I even dropped my boyfriend, become very confident and because he had many partners. I have made a free capable. Observations in the choice about my life. I am abstaining from sex and field also showed that FOs alcohol, because I want to remain negative“ are accepted by the young and the elderly. A number of stakeholders mentioned that the younger age of the FOs is in fact an advantage as 1) the majority of the Namibian population is young and they can easily communicate to people of their own age group and 2) a lot of energy is required to cover large distances to move from house to house. Gender was also mentioned to make no significant difference in the functioning of the FOs.One third of the FOs are male and two third are female. This is similar to the composition of the general population due to male migration to the South.
5.1.3 Internal meetings Considerable amount of time is spent on internal meetings. For instance, half of the working week of Division Commanders, Deputy Division Commanders, Troop Commanders and Special Forces is spent on meetings. On Thursday afternoon the Troop Commanders and Division commanders meet at the divisional office to prepare the agenda and logistics for the Friday troop meeting. The whole Friday is spent in the troop meetings of 50 Field Officers per troop. The purpose of the Friday meetings is to cross check the weekly monitoring data, education (1,5 hrs) of the FOs, proffer solutions to problems encountered in the field by the FOs, planning for the next week and to create a communal sense among TCE staff. DAPP considers these Friday weekly meetings very essential for staff motivation and reaching the weekly goals.
DAPPœTCE Programme Evaluation | May/June 2008 9
On Mondays the Division Commanders, Deputy Division Commanders, Troop Commanders and Special Forces meet to discuss the weekly monitoring results and other issues. This leaves 2 to 3 days for key staff to spend in the field to monitor and assist the FOs. At the Division Commander level there is also a monthly two day meeting to further discuss the programme, FO performance, obstacles and management issues. The higher level management œ Corps Commanders and including the Division Commanders œ participate in meetings every other month at Humana People to People HQ in Zimbabwe to discuss results achieved or not achieved, what to do about it and further develop the programme across borders. Changing lives of Field Officers FOs are encouraged to prepare case studies on how The economic costs in terms their lives have changed as result of their work with of man -hours measured by TCE. Below is the excerpt from a female Field Officer: the number of people involved and the time spent —On August 2005 I went to DAPP training center for on meetings seems to be Field Officer initial training….This time I was a high, particularly with sexually active girl with 2 partners. In general I heard regards to related transport about HIV/AIDS but I don‘t know what is it in deep. I costs. The evaluators do do not love them but I was dependent on them, as recognize that it requires they are my support. I saw the TCE facilitator speak considerable efforts to English only. How could I communicate with them? I manage such a large number was shy to be laughed at by my colleagues, because of staff, especially when of my poor English. I took a seat in the back, so that many of them require no one would point at me to say anything. I was not intensive on the job training. comfortable when people talked about sex, because I It also requires additional did not think it is important to talk sex in public effort to move everyone in openly. I also thought that girls had no equal right as the same direction and boys in sex issues. Talking in front of people was my ensure that weekly targets big problem and at that time I did not know my HIV are met. However, status. …TCE totally changed my life…Now I can talk consideration could be given English and not shy anymore of my poor English as whether in the later phase of long as I communicate. By learning HIV/AIDS, I know the three-year campaign; more than before. I totally changed my sexual the weekly meetings could behaviour, I choose one partner, the one I loved be replaced by bi-weekly or most, because I learned the high risk of HIV. I can perhaps monthly meetings. take decision of sex with my partner easily and had a chance to put condom on, with no shame. Let me tell you! Now I know my HIV status. I can go for HIV 5.1.4 Staff turn over testing for any single mistake that could put me at The staff turn over of FOs risk of HIV. ……By moving around, I got more has been high in some areas experience on how to communicate with different but less in others. TCE people…. management indicated in an initial interview that staff turn over of Field Officers has been around 40%. Staff turn over is higher in urban settings where there are more alternative job opportunities. A number of FOs have left to join the Red Cross as community counsellors in Ohangwena and Oshikoto. However, the Red Cross does not have community counsellors in most of the areas where TCE is implemented with support from GFATM. A number of FO have also been promoted to other positions within TCE, e.g. the malaria programme or have become a Special Force. The FO are replaced by people who have functioned as TCE volunteers, the so-called TCE passionates. It takes additional time and effort to train these volunteers and not all have gone through the complete basic training.
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5.1.5 Finances Although the evaluation team did not specifically look at the financial management capacity of TCE, it was evident from discussion with management that the organisation has sufficient capacity and a solid structure to expend financial resources. The cost per person reached (approximately US$ 6) is also commendable. The major concern as earlier indicated is the cost of keeping up such a top heavy structure. Another concern is that TCE does not have sufficient funding or fundraising strategy. The DAPP programme was previously known for its ability to raise funds, for example, selling of second hand clothes. However, this activity came to an end when government changed the import laws in year 2000 resulting in higher custom duty which made the activity no longer profitable. While this resulted in difficult times for the organisation it also paved the way for new fundraising strategies such as partnerships with government, UN, development partners and private sector. However with the rapid growth of the TCE programme and the obvious needs to do more in the communities a new challenge to sustain a presence and activities in the regions has emerged.
5.1.6 Monitoring and evaluation The monitoring system put in place has the potential to become a very rich information base. Field Officers have household register books with a special page for each household visited. The same page is used for subsequent visits. The page provides data on which members of the household have been met, whether they have taken a HIV test, have passed a special TCE test, etc. The data of all visits is compiled on a weekly basis, and cross-checked by other Field Officers during the weekly Troop meetings. Surprise visits by Special Forces, Troop Commanders, Division Commanders and Deputy Division Commanders also function to check the data. The data is entered on a weekly basis into the computer system. However, because of the way the data is entered in the system, it cannot be used easily to analyse for instance how many individuals have been reached only once, twice, thrice, etc. A revision of the system through which more thorough analysis could take place is strongly recommended.
5.1.7 Conclusions The programme is very well managed and the management structure well thought out. The supervisory and monitoring structure is one of the strongest the evaluators have come across so far within community-based programmes. All of this ensures that the programme can be implemented according to plan and that the monitoring data collected are of high quality. However, in the current management structure considerable resources are invested in supervisory/management staff with considerable time spent on meetings. Consideration could be given to a somewhat leaner management structure, fewer meetings or fewer people participating in meetings, especially once the programme has been well established. In spite of this, the cost per person reached through the programme, is still very low because of the large number of people reached. Poor data utilization and dissemination remains a concern despite the rich monitoring data collected. Efforts to create a more robust database that will allow for improved data synthesis and data use is strongly recommended.
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5.2 Approaches
5.2.1 Door-to-door approach Nearly everyone interviewed by the evaluators, from door-to-door clients, traditional headmen, health staff, to Governors, mentioned the added value of a door-to-door and as result face-to-face approach. While media such as radio may reach large numbers of people, the advantage of a face-to-face approach is that people can raise questions and or concerns they may have. This was evident in every place that was visited as part of this assessment. For example, following a group meeting with people in a cuca shop (local bar), people raised questions ranging from treatment issues to myths around condoms.
TCE Field Officers, easily recognizable in their uniforms consisting of a red T- Shirt and a barrett, are seen as hard workers with real concern for the community. Because they move from door-to-door, they also get in contact with people who were initially not interested in discussing HIV. Case studies written up by FOs indicate that because of their persistence, they were able to engage with quite a number of people who might otherwise never have spoken out about HIV. One TCE passionate also mentioned: —People want to have private, individual discussions. TCE has helped to make community members more open about HIV. As result TCE staff have become very close to the community“. The Governor of Omusati said that he had seen that —some people are now even demanding that TCE FOs visit them“.
Concerning the door-to-door visits monitoring data shows that the time FOs spend with individuals at household level varied considerably. In some cases 45 minutes to 1,5 hour is spent but in other cases just 10 to 15 minutes. If sufficient time is spent, the FOs can have real in-depth discussions but if only 15 minutes is spent, the conversation may stay at a very superficial level.
Through the door-to-door approach the TCE programme also reaches out to the —far corners“ of the areas they cover, areas that can only be reached by foot as they are not accessible by road. This was mentioned and appreciated over and over by representatives of local/regional bodies, NGOs, community members, TCE passionates and others. Through the door-to-door approach FOs have also been able to pick-up other issues that concern people in the communities, such as problems with water taps, food shortage, access to services and report these to the authorities.
Leveraging on the large coverage through the door-to-door approach, other organizations have used the TCE FOs to deal with some emerging challenges. For instance, staff of clinics/hospitals showed lists with names and cell phone numbers of TCE Field Officers, whom they would call for ARV or TB defaulter tracing assistance FOs help to trace people and ensure that those who have not moved away or have died, resume and complete treatment by re- establishing contact with the health system.
One of the big challenges of TCE FOs is that they have to visit a household many times before they meet every individual living in that household. And in spite of FO making efforts to visit remaining individuals in their work places wherever possible (fields, hairdressing saloon, cuca shops), there will always be individuals not reached. Furthermore, because considerable numbers of male spouses work as migrant workers in the South and only come home during Christmas, they are also not reached by the programme.
The household registers which the FOs carry with them to keep track of whom and how often they have met every individual contains a wealth of information.
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More could be done with this information both for internal and external purposes i.e. for tracing of orphans and vulnerable children.
The major goal of the TCE programme is to mobilise the community to take control of the epidemic. This is through a one-on-one approach, going from one house to the next and providing comprehensive prevention campaigns, counselling and mobilization services. As discussed earlier, the aim was that each of the 290 FOs would cover 2,000 people, resulting in 580,000 people being visited in total during the entire three year campaign. It was further envisaged that each individual would be visited about 6 times during this period. The current data shows that a total of 694,000 people have been visited, meaning that each FO is on average responsible for 2,400 people. This is because the 2001 census statistics used to delineate the fields do not represent the actual situation anymore. At the time of project design, the conceptual framework did not make adequate provision for projected changes in the targeted populations The implication is that each person is now visited only 2-3 times on average instead of the 6 times envisaged and each visit taking less time than desirable.
While this is understandably due to the higher work load and the large distances to be covered, there is a potential risk of compromising the quality of the work of the FOs. The quality of work the FOs provide would improve were more training tools provided and more time set aside for each of the visits. Many of the key respondents we spoke to agreed that two or three visits are not enough to instil the required sense of ownership and empowerment needed to effectively deal with HIV.
5.2.2 Number of people still being registered (first time contacts) in 2008 Data from the TCE household registers show that a number of new clients are being registered every week. This is in addition to the 694,000 people already registered since the inception of the programme. For instance, during the last week of the field visit, we noted that Troop One, Division 2, alone registered 234 new people. This creates the impression that many people have not yet been reached, thereby defeating the TCE‘s strategy of exposing every individual in the community to this campaign. This is probably because of the high mobility and the increase in people living in the targeted communities over and above the 2001 census. The communities acknowledge the relevance of the TCE programme, and although communities do not intend to abdicate their responsibilities, they see a need for TCE to encourage all individuals to deal with HIV positively. Although we were not able to ascertain if all the community leaders have been exposed to the TCE campaign, it is clear from those community leaders visited that the TCE work has increased their sense of urgency and responsibility in addressing HIV. This is a key achievement of the TCE programme. TCE clearly recognizes the important role of community leadership in helping to reverse the epidemic. TCE also acknowledges that communities have within themselves the resources and the capital to confront the epidemic and to promote changes in community norms, thus creating an enabling environment for their women and men.
The current data show that about two thirds of all people reached are women, reflecting that many men are not at home during the day. A considerable percentage of men have gone south in search of work. Also two third of the FOs are women. The obvious dominance of women in this programme has profound implications for its impact. Until gender power relations have become more balanced, success must be understood in the context of the contradictions and tensions of gendered relationships. The challenge for the TCE programme design is to develop and implement strategies that will involve
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more men in their services while simultaneously continuing to motivate women.
5.2.3 Peer Support Groups A number of TCE FOs assisted PLHIV with starting peer support groups for mutual support purposes. The support groups have also helped to motivate people to seek ARV treatment, to adhere to treatment, to support HIV positive wives kicked out of their homes by their husbands, build bridges between people infected and family members, etc. Respondents indicated that for most PLHIV support groups, income generation activities were important for the well functioning of the group. Several people interviewed said that membership of support groups with successful income generation was increasing, while membership of groups without such activities decreased after some time. In division 2, two support groups have been able to mobilize external funding for the construction of a kindergarten and for gardening respectively. A number of income generation activities were observed but it would be beneficial for the groups if more technical assistance could be provided to increase the profitability of these activities. The limited income generated by the different groups, was said to be used to provide transport money to clinics/hospitals for treatment purposes and food in relation to treatment.
Efforts are being made to link these support groups with activities of other stakeholders, i.e. with Red Cross volunteers where they exist.
5.2.4 Vulnerable groups Efforts have been made by TCE to cover certain vulnerable groups but mostly through incidental activities. One-off actions for i.e. truck drivers and taxi drivers where a number of FOs jointly cover a number of people have been organized. Sex workers are sometimes reached through house œto-house visits. No special efforts to reach out to MSM during door-to-door visits are made. Incidentally orphans and vulnerable children have been reached. .However, there is no specific strategy to do so within the TCE programme, since there is no funding available for this. There has been a one-off activity for OVC in Omusati in 2006, when 1,000 OVC received school uniforms, school materials and other support. DAPP does however implement programmes with orphans and care givers in Omusati, Kavango and Ohangwena regions with funding from other partners including UNICEF. TCE data and contacts are used to identify those communities and families most in need and who do not receive any other assistance.
5.2.5 Conclusions The door-to-door and as a consequence, the face-to-face approach is highly valued and effective. It is culturally appropriate and allows people to raise many questions regarding different issues around HIV. TCE has been able to reach people in remote rural areas who were not being reached by others œ including mass media œ or who were non œreceptive to HIV and HIV related issues. The door-to-door approach has also facilitated the setting up of peer support groups and motivated PLHIV to take part in these groups.
This approach is quite demanding on the Field Officers, as they often have to make a lot of effort to reach everyone within the household. This concern is important , especially as it relates to those not at home during the day or during specific times of the year, among them many men, who are yet to be reached. Notably, activities for vulnerable groups such as female sex workers,
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alcohol users, people engaged in multiple concurrent partnerships, MSM, etc have mostly been incidental or in the case of MSM, not taken place.
5.3 Tools used for TCE Implementation
5.3.1 Tools for door-to-door outreach The FOs are expected to visit every individual between 3 œ 6 times on average during the campaign period.
During the first visit, the F.O. registers in her/his household register all the individuals living in the household and introduces the programme (to those people present). During the second visit, the FOs provides HIV information to the individuals present on a one by one basis. If a person does not have a good understanding of HIV/AIDS, has misconceptions, or is not practicing safer sex, the FO will help the person to make a risk reduction plan. This plan entails the steps the person needs to take to get in control of HIV in his or her life. During a third visit œ or fourth, fifth, etc, if the person needs more time, the FO undertakes a so-called Perpendicular Estimate System (PES) assessment with the individuals whom he/she has provided information during the second visit. There are three PES score-cards, one for individuals below 15, one for individuals above 15 and one for pregnant women. At the beginning of the session, the individuals are asked to which category they belong, so that women who are pregnant in the initial phase can self-identify. The score system looks at HIV knowledge, testing, how people will remain negative or not pass on the virus and how they will be part of the TCE movement.
The PES assessment cards provide a clear structure for the FOs to work towards and around. However, the actual scoring differs from one FO to the next. More flexibility in how the PES is conducted may make it a more engaging and useful tool. For example, we met with a young woman with a one month old baby. The FO went through the PES from the start to the end at a very slow pace, when it was very evident that the woman was very knowledgeable and had in fact answered a number of questions in one go. In this case it would not have been necessary to go through each question again. A good starting point would have been to ask her whether she had participated in the PMTCT programme. Another good starting point when dealing with younger people would be to ask whether they had participated in My Futures My Choice or other activities and the rationale behind that choice.
Besides the PES, there are no existing tools with which FOs can use to discuss issues around concurrent partnerships, male circumcision, sexuality, gender inequality, condom negotiation, female condom use, alcohol use, MSM, etc. with the exception of some leaflets produced by MOHSS, the TAKE CONTROL campaign and other NGOs on some of the issues. Of interest is the absence of any officially approved materials on multiple concurrent partnerships and male circumcision. While the FOs are informed and updated about new information in relation to HIV, at the national levels, no tools have been developed to assist them with addressing these issues during the house-to-house visits.
5.3.2 TCE Compliant Upon passing the PES (with 85 points out of 100), individuals are declared TCE compliant. Available monitoring data shows that in the MOHSS/GF areas over 400,000 people are believed to be TCE compliant or in other words have passed the PES test. Two of the door-to-door persons we interviewed indicated that they had seen the card of other persons and that they were eager to get a card too. Others did not know where their card was, or whether household
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members had obtained cards. Others could show their card but not explain what TCE compliance really meant. When observing the FOs taking clients through the PES assessment process, it was also clear that people were confused about the TCE compliant concept. Beyond the PES card, there is no structure in place to monitor whether people who are declared compliant, actually follow the compliancy rules (1. knowing your HIV status, 2. staying HIV negative or when HIV positive not infecting others and 3) becoming involved in activities for the community around HIV).
5.3.3 Conclusion The PES tools provide clear guidance on the field work for the FOs. .It is a very useful tool especially at the beginning of the programme when the FO are not yet well trained. However, the usefulness of the tool could be improved when it is used in a more flexible manner. Respondents interviewed by the evaluators were not able to explain the meaning of the TCE compliant concept. Tools through which drivers of the epidemic could be discussed or tools that would provide further insight into what the TCE compliance concept means are currently not available.
5.4 Capacity Development and supervision
5.4.1 Training of staff The Field Officers have to follow three training modules. The first training is part of the recruitment process. Field Officers under recruitment have to follow a four week basic training course, consisting of three weeks of theory and one week in the field. Participants who successfully complete the training are hired as Field Officers. The second training is a counselling training which focuses on HIV testing. The third training is about education and geared towards developing lesson plans for in-school activities. The second and third training are not full time. The FOs have to prepare assignments at home which are reviewed and commented Changing lives of Field Officers upon on a piece by piece F.O. are encouraged to prepare case studies on how basis by Special Forces. their lives have changed as result of their work with There are financial TCE. Below is an excerpt from a 26 year old male Field incentives for the FO to Officer: complete the counselling and education training —At the beginning the work was so difficult for me, courses. Upon completion because I was a little bit shy to speak about sexual of the counselling training issues openly to people. ….I had to give myself Field Officers monthly pay confidence to carry forward with my work. The TCE is increased from N$ 700 programme is very well organized in Namibia and to N$ 800 (45 hour experienced trainers and nurses, counsellor and other working week). Following people from MoHSS gave us more information on how the education course, the the epidemic affects our development and how to monthly pay is again promote health and life expectancy for the people. ….I increased with another also gained more experience on how to be with people, N$ 100. In spite of these how to answer the question ,how to organize meetings, incentives, it has taken gathering or plan the work, how to solve problems in many FOs nearly 1,5 year general — to complete the counselling training (supposed to take around 6 œ 7 month) and quite a number of FOs are only just now completing or have recently completed the education training. This means that these FOs have not been able to draw upon counselling and education approaches during their first years as FOs. Whereas most FOs observed during door-to-door visits engaged really well with their clients, it
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would likely have had a positive effect on the effectiveness of the work if they had more understanding on how other people learn and how to facilitate this learning from their first day in their job.
Top level management staff at the (deputy) division commander and corps office level have undergone training at one of the DAPP/Humana training centres in Europe or Africa. Several people in those positions have started and or worked in TCE programmes in other countries (Botswana and Zimbabwe). A number of DAPP/Humana training center students join the TCE programme as Development Instructors for a 6 month internship. They are responsible for training FOs and Special Forces. However, as it takes a while before these Development Instructors are fully functional and come with different educational back grounds and experiences, this may hamper the consistency in training approaches.
Special Forces positions at troop level are often filled by people who started working as FOs. Although they work in specialized area (education, coordination, M&E, etc.) they do not have an educational background for these positions. In most cases this hampers the effectiveness of these positions.
5.4.2 Quality assurance/support to FOs Field Officers are directly supervised by their Troop Commanders and Special Forces. Troop commanders and Special Forces spend 2 to 3 days in the field to supervise FOs directly or indirectly through checking with households if they have been visited. Division and Deputy Division Commanders and Special Forces at the Division level also spend 2 days per week in the field to monitor activities. Visits can be announced and unannounced. Trip reports are prepared of these visits and on file at the division level. In trip reports suggestions are given on how FOs can improve their work, i.e. if they visit a certain area more than another in their assigned geographic area, they are suggested to change this. All problems encountered in the field by FOs are brought up during the Friday troop meetings for discussion on how the problem can be resolved. Special support is also provided for FOs who have to cover large geographic distances through mobilizing additional FOs for a number of days to assist these FOs with door-to-door visits.
5.4.3 Skills mix of FOs It is evident that different FOs have different strength and weaknesses. Some FOs have been found to be really good at setting up peer support groups, others at organizing educational sessions in cuca shops, others at running youth clubs, etc. At present, FOs only exchange information at the troop meetings on how they do things and no —work visits“ or —twinning“ between different FOs takes place. To further develop the requisite skills , continuing on the job training through —twinning“ might be considered.
5.4.4 Training modules The training manuals for the FOs (basic, counselling and education training) have not been adapted to the Namibian situation. The same manuals are used in all other countries where TCE is implemented. The counselling manual i.e. focuses on testing as in some countries TCE FOs conduct rapid HIV tests in the Field (Angola, Zambia). In Namibia Field Officers are not directly involved in the HIV testing process. In the case of Namibia, it would therefore have been more appropriate for the counselling training to focus on actual tasks of the FOs such as bereavement counselling, counselling on gender inequality issues,
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concurrent partnerships issues, etc. The manual also pays very little attention to post-test counselling for those who have tested HIV negative.
The initial training only has a 60 minute session on communication, while the whole programme depends on the communication skills of FOs. Several case studies prepared by the Field Officers indicate that they found it hard to discuss sensitive issues at the onset of their work. Communication skills building within the basic training (including listening, two-way communication, discussing sensitive issues such as sexuality) could have provided FOs with an easier start and made the programme more efficient right from the beginning. The initial training also does not address the (emotional) problems the FOs face at the onset of the work. Although these problems are being discussed at the troop and patrol meetings, it could also be taken up in the initial training.
The counselling and education manuals are meant for self-study. Students have to write assignments to tasks given in the manuals spread out over the course of a number of months. For the counselling manual, around 30 assignments have to be completed. The assignments are reviewed by Development Instructors. As English is not the first language of the FOs, the tasks have been quite challenging. Mid way and at the end there is a special test which the FOs have to complete in the presence of other TCE staff.
More intensive hands-on/participatory training approaches instead of self-study would have made it easier for the FOs to finish the courses earlier. This could have also broadened the communication/facilitation skills of the FOs. While the Friday troop meetings also have 11/2 hour build in for education purposes, groups of 50 people are simply too large for everyone to learn effectively.
The TOT manual on Nutrition and HIV and Income Generation does not include any reference to facilitation skills development to implement the training.
5.4.5 Conclusions Case studies prepared by the FOs, observations in the field and feedback from people in the field indicate that the FOs in general have developed good communication skills over the course of the programme. However, the training itself could be improved by focusing more on communication skills upfront, making the training courses more participatory and interactive focusing on building different skills, and ensuring that the training is completed in an earlier phase of the programme and not towards the end of the three year campaign.
5.5 Effectiveness of the interventions and changes observed
5.5.1 Role modelling œ knowing your status and being open about it In the initial stage of the programme, the FOs and other staff had not been tested for HIV themselves. However, in 2006/2007 TCE started to encourage all staff to know their own status. It took approximately 6 to 9 months before everyone had gone for the test. While staff do not have to share their results they are encouraged to share them with at least one or two others for support purposes.
The fact that staff have gone through the VCT process has positively contributed to the programme. Attitudes of staff have changed and they can talk to door-to-door clients from personal experience. From the international staff, one person is open to everyone about her (positive) status. This sets a very inspiring example for the rest of the staff as well as for the communities.
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While a number of FOs are open about their HIV positive status, there have been two incidences of HIV positive FOs who nearly died because of not wanting to admit they were infected and therefore did not want to access ARV treatment. This shows that there are still more efforts needed to address self- stigma. Division 2 has a support group for HIV positive staff. Around 20 staff meet in this support group on a weekly basis.
5.5.2 Uptake VCT, ART, and PMTCT When respondents at the household level were asked if they were tested, many said yes. This is very encouraging, especially since a sizeable number of the people reported being tested after meeting with the TCE FOs. A key respondent from one of the New Start Centres remarked that —since TCE started in this community, our workload has tremendously increased…. and we thought of telling them to Changing lives of Field Officers take it slow“. F.O. are encouraged to prepare case studies on how This sentiment was their work has changed people‘s lives. A story written shared by all those who by a female field officer called Theopolina were involved in the national testing day Shetulima, 39 years of age, lives together with her 5 where the turn up far orphans (children), but they have nothing to eat or to exceeded expectations. wear. Among those orphans, no one received The centres (both free government support. This woman has suffering from standing and hospital HIV together with 3 children, a son and two daughters. based) had to remain I met with them for 5 times. I asked the women why open until late at night to she did not register her children under government cope with the demand. grant, then she explained that they don‘t have Data obtained from the husbands death certificate. Then I told her what to do Oshakati Hospital show and where to go so that she can get help…When I revist that the total number of them and found this women waiting for me with lot of people tested during the appreciation for what I have done for them. But still I three day campaign in found her having some questions about ARV procedure Oshakati were 3,165, of because she is on ARV and her 2 daughters but her son which 253 (or 8%) were is also HIV positive but not yet on ARV. At this chance I positive. At the Outapi have asked her what their doctor said, then she said: he New Start Centre, the is always telling me to come back, but nothing has been number of people tested done. Then I have to explain that it means that her son during the same was not qualified to receive ARV due to too much CD4 campaign was 280, of count. If his CD4 count drops, he will go through usual which nine (or 4.3%) procedure. After 5 weeks I meet her again. She were positive. Many explained that she is now good, her son is now on ARV linked this uptake œ and all of her children are now receiving government among others - to the support. She was looking healthy and happy. Also I was work of the TCE FOs in happy for successful job. the community. The referral card used by TCE FOs since mid 2007 is a tool to track the number of people referred to VCT by TCE. The New Start in Outapi received for instance 323 referral cards between June 2007 and April 2008.However, not all cards are being handed in and some people just verbally mention that they have been referred by TCE. It is therefore unfortunately not possible to make a meaningful conclusion on the actual number of people who went for VCT as result of TCE.
VCT has been shown to be a cost-effective HIV prevention intervention if it includes behaviour change communication for those who tested negative to remain negative. It is also an entry point to a wide range of care and support services. The increase of resources through the Global Fund (GF) for treatment,
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and the development of increasing numbers of effective and accessible medical and supportive interventions for PLHIV mean that VCT services are being more widely promoted and used. The added value of the TCE FOs is that they are able to clearly explain that the benefits of VCT in the era of ARV treatment far supersede the challenges of knowing your result. With the TCE‘s intervention, acceptability of VCT is increasing and many people have either gone for a test or are now prepared to undergo VCT.
Table 1: VCT clients in the period 2005 œ 2008 2005 2006 (9 month) 2007 2008 (6 month) Omusati (population 228,842) 4,844 7,730 10,983 4,183 Oshana (population 161,916) 3,070 11,324 21,558 9,580 Ohangwena (population 228,384) 5,869 7,153 6,418 Oshikoto ( population 161,007) 9,949 14,107 9,199 Caprivi (population 79,826) 998 3,171 6,259 3,987 Erongo (population 100,663) 25,923 5,798 15,196 5,647 Hardap (population 68,249) 1,351 992 2,309 ,916 Karas (population 68,329) 472 1,623 4,678 3,809 Kavango (population 202,694) 3,496 4,480 9,172 2,605 Khomas (population 250,262) 8,594 8,087 9,608 4,148 Kunene (population 68,735) 2,309 4,506 3,005 Omaheke (population 68,039) 1,307 3,994 2,815 Otjozondjupa (population 135,384) 1,283 2,709 5,767 4,261
Source VCT data: MoHSS ) Population data: Census 2001 2005 data New Start data only
The table above provides an overview of the number of people tested per year in the different areas since 2005. As can be seen, the number of people tested in the (shaded) TCE areas is high compared to most other regions. However, it has to be taken into account that the TCE regions are more densely populated than other regions. When calculating the percentage of people that have gone for VCT in the TCE versus the non-TCE areas, no real differences could be observed between the two. It has to be taken into account that women who undertook a HIV test as part of the PMTCT programme are not included in the data above., while TCE Field Officers undertake special efforts to motivate pregnant women to go for testing.
The fact that VCT uptake is relatively high is also facilitated by the wide availability of antiretroviral medication in the major public health centres in Namibia. All respondents said that through the house-to-house approach, the TCE programme managed to decrease stigma, thereby encouraging potential clients to come forward and be tested. The advantage of this programme is that the FOs are local residents known to the communities in which they work, and are to some extent equipped with basic skills for clinical evaluation of clients with possible AIDS related symptoms and provide encouragement for these people to seek treatment. This actually creates a significant opportunity for improving health seeking behaviours among community members and to improve the link between the community and the health centres. This approach has undoubtedly increased community awareness of ARTs and related services, and increased self-acceptance and created the platform for the advancements of the need of people living with HIV and AIDS and those on treatment. Consequently, health staff believe that the FOs act as a gateway to treatment, care and support. The health staff that we spoke to are also adamant that the TCE approach of door-to-door is providing a formidable tool 20 DAPPœTCE Programme Evaluation | May/June 2008
for surveillance of pre-ART and post-ART chronic care and greatly facilitates the expansion of ART care. Also, it is reported that the FOs play an important role in maintaining adherence levels as they are used to track patients on ART and TB treatment and in many cases, act as treatment supporters or encourage Passionates to serve as treatment supporters. There are also suggestions that the FOs could add value by providing additional services such as treatment literacy and adherence counselling.
Similarly, the targeted focus on pregnant women provides yet another opportunity for the identification and referral of pregnant women. As a result, the number of women referred for PMTCT services by the FOs is said to have increased substantially. For instance, records show that in 2006, the Outapi Regional Hospital tested 3,678 pregnant women of which 725 tested positive (19,7%). The number of pregnant women tested in 2007 increased to 6,249, with 583 testing positive (9%). Some key people from the health sector suggest that this incredible increase is linked to the community activities such as those undertaken by the TCE FOs. Although this data and those of the national testing day are anecdotal, they provide a good indication of the magnitude of the HIV situation in the TCE areas and the TCE programme could pride itself with the contribution it has made towards this.
Table 2: HIV prevalence ratios by site for the years 1992 œ 2006 Region Sentinel site 1992 1994 1996 1998 2000 2002 2004 2006
Caprivi Katima Mulilo 14 25 24 29 33 43 42 39.4 Erongo Omaruru Clinic 16 Swakopmund 3 7 17 15 22 16 28 17.3 Walvisbay 29 28 25 26 22.1 Hardap Mariental Health Center 10 12 11 10.2 Rehoboth 3 9 10 14 13.9 Karas Karasburg Clinic 22.7 Keetmanshoop Clinic 3 8 7 17 16 16 18.5 Luderitz Clinic 22 22.5 Kavango Andara Hospital 2 11 16 15 21 18 22.7 Nankudu Clinic 13 18 16 19 13.9 Nyangana Hospital 6 5 10 16 22 15 10.2 Rundu Clinic 8 8 14 14 22 21 20.1 Khomas Katatura State Hospital 4 7 16 23 31 27 22 21.7 Windhoek Central Hospital 10 9.1 Kunene Opuwo Clinic 3 1 4 6 7 9 9 7.9 Outjo Clinic 12 12.1 Ohangwena Eenhana Clinic 21.4 Engela Clinic 7 18 17 23 19 19 27 Omaheke Epako Clinic 1 9 9 13 13 7.9 Okahao Clinic 22.5 Omusati Oshikuku 0.21 27 27 22.4 Outapi 23 17 20.7 Oshana Intermediate Hospital Oshakati 4 14 22 34 28 30 25 27.1 Oshikoto Onandjokwe Clinic 8 17 21 23 28 22 23.7 Lombard Clinic 25 16 17 Otjozondjupa Grootfontein Clinic 9 30 28 19.3 Okahandja 18.5 Orwetoveni Clinic 2 9 16 18 25 17 18.7 DAPP Global Fund TCE Areas Source: 2006 National HIV Sentinel Survey. Table 9
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Namibia relies on the Sero Surveillance survey as a proxy of the prevalence of HIV. The Sero Survey is undertaken every two years at selected number of health facilities, and the last survey undertaken in 2006 shows HIV prevalence of 21% at Outapi (Omusati), 27% at Oshakati (Oshana), 21% at Eenhana (Ohangwena) and 17% at Tsumeb (Oshikoto). Unfortunately, this cannot be used to ascertain the impact of the TCE intervention in these areas, because it was undertaken only 9- 12 months after the TCE intervention started. The surveillance data in the table above demonstrates that there is no clear correlation between fluctuations in prevalence rates and TCE activities in 2006. This however could also not be expected as already explained in the limitation section of this report. The 2008 survey is now under way and results are only expected during the later part of 2008. However, the 2007 results from Outapi paints a very interesting picture of only 9% of pregnant women being positive compared to the 21.1% as per the 2006 Sero Survey. If these results from the Outapi Hospital are anything to go by, there is an obvious curiosity of the factors that led to such a remarkable drop. However, it has to be taken into account that pregnant Changing lives of community members women may not be the best group to indicate the F.O. are encouraged to prepare case studies on how impact of the their work has changed people‘s lives. A story written programme, as they œ by by a female field officer called Justina. definition œ have had unprotected sex. —From 2005 up to 2008, my success is that from the people I mobilized to get tested, already 25 people started ARV, most of them women…Men do not want to 5.5.3 Condom distribution and get tested…A (very sick) woman wanted to get tested use and after starting ARV, her body started to All FOs have a number of recover…Soon after that I find a man looking for me cuca shops, car wash asking for information. When I give him information, he outlets, or other venues get tested and also started ARV. He became my through which —smile“ passionate and one who encouraged me to work very condoms are being hard because when you find him you can not believe distributed. Members of it. especially remote communities have now much better access to condoms because of these outlets which are being stocked up by the FOs on a weekly basis.
All FOs have dildo models and conduct condom demonstrations during house- to-house visits. They also ask clients to do condom demonstrations for them to check their skills. While the FOs are doing this very well, the last part of the demonstration, where they remove the condom from the dildo, could be improved. They advise clients to use tissue/toilet paper in order to avoid touching the condom and possibly vaginal fluids. However, it is not demonstrated how people should do this, and how they could tie the condom while holding it with a paper (it is questionable whether this is actual feasible). Instead they could suggest that the woman removes the condom and that hands are washed with soap and water afterwards. While female condoms are demonstrated as standard practise, it is questionable how useful this is if they are not or hardly being made available.
TCE collects these ”smile‘ condoms once a week from the MoHSS regional/sub- regional distribution points. In the GF TCE areas, over 10,5 million condoms have been distributed since the start of the programme. However, TCE staff in Division 2 believes that the number of condoms distributed on a weekly basis could be at least double of what is currently distributed. The bottleneck is the availability of condoms at the regional hospitals. Division 2 also has problems with accessing Female condoms. Compared to the TCE baseline in 2004,
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condoms have become much more available. Respondents also indicated that talking about condoms has become less sensitive.
Data from the 2006-7 DHS show that the knowledge of condom use as a prevention method is high among both men and women, with 84% mentioning condom as a prevention method. The DHS also showed that there is no difference between rural and urban areas on the major HIV prevention methods. People interviewed believe that condom uptake and use has increased in the communities in which the TCE programme operates. For instance, FOs mentioned that it is now harder to reach their weekly target of pregnant women and said that this might be the result of an increase in condom use resulting in fewer pregnancies. A regional health administrator said that the immunization targets were harder to reach compared to a few years ago, and believed this to be the result of fewer children being born as result of among others increases in condom use. Some respondents also mentioned that teenage pregnancies are on the decline. If what these respondents mention is true, this could suggest that the current TCE strategy of matching condom availability with condom promotion bears results. It is obviously not enough to just provide condoms without educating communities on correct and consistent use of condoms and the benefits of condoms as a prevention method for HIV and sexually transmitted infections. The major loophole of the TCE programme, however, is that it focuses more on general HIV education rather than on behaviour change that addresses underlying factors driving HIV. In order to promote behaviour change among the communities in the TCE areas it is critical that the TCE embarks on the use of participatory approaches which challenge communities to confront, reflect on, develop their own responses to, and build their own normative consensus concerning sexual values and practices. Data from previous studies also show a lack of inter-generational communication and dialogue across and in same sex genders around, sex, sexuality and HIV within the communities in which TCE operates. This is a missed opportunity by parents and elders in the community to contribute to the education of their young ones on unsafe sexual practices and changing community norms.
5.5.4 Stigma, discrimination and general perception of HIV Almost all the people we spoke to report a high level of acceptance towards people PLHIV and part of this is attributed to the work of the TCE FOs. Because Namibia is experiencing a generalized epidemic, everyone is affected by HIV in one way or other. The high levels of understanding and empathy towards PLHIV are therefore not surprising. However, although the acceptance of PLHIV is high, stigma and discrimination are still very much present. A finding which the latest DHS further corroborates . Testing positive and being sick with an AIDS related disease still invites stigmatization and discrimination by others or one-self. This contributes to people‘s reluctance to disclose their status, further fuelling the spread of HIV. Positively, all the TCE officers have undergone VCT and one of its key staff member lives positively with HIV. Visibility and openness together with provision of adequate services about HIV/AIDS is paramount for the successful mobilization of all stakeholders to respond to the epidemic. Inadequate services and concealment encourages denial that there is a problem and delays urgent action. This indicates the need for the TCE programme to educate the communities on the negative impact of stigma. Strategies involving PLHIV in both program design and implementation will be key to any successful intervention wishing to reduce stigma and discrimination, leading to open discussion around HIV. TCE is commended for their effort to motivate all their FOs to get tested for HIV. Because of this, they are now able to effectively deal with the issues confronting them and their
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communities. In addition, they also stand a good chance of accessing treatment and receiving the necessary support if they are infected and fall sick.
Additionally, there is a widely held belief that people‘s perception about HIV has changed over the past three years as a result of the TCE activities in the communities. According to one community leader, —people now feel that HIV is part of their business“, unlike in the past where people demonstrated careless attitudes towards HIV.
5.5.5 Addressing the drivers of the epidemic Despite the achievements as described above, the overall outcome of the TCE programme will be measured in terms of its contribution to the reduction of HIV incidences in Namibia. The greatest challenge in Namibia is that although knowledge on the routes of HIV transmission and methods of prevention are high, there is no clear indication that this has resulted in a high degree of behaviour change. DHS 2006/7 data show substantial levels of inconsistent use of condoms in non-regular sexual partnerships, substantial numbers of people not using condoms with regular partners and a high level of engagement with multiple partners.
The current TCE approach is based on the principle that interpersonal communication reinforces messages that individuals receive from sources such as radio, television and newspapers. Although this is commendable and highly praised within the communities in which the programme operates, this does not necessarily address the key issues that drive the epidemic. Until there is a vaccine or affordable treatment, the priority should remain on the prevention of new infections through risk behaviour reduction, with a focus on the key drivers of the epidemic such as concurrent sexual partnerships, transactional sex, early sexual activity, intergenerational sex, alcohol and substance abuse, violence, male circumcision, and men having sex with men. Special attention should also be given to the most vulnerable groups such as children and young people, who are particularly vulnerable to HIV. Clearly, it is the young people who are the window of hope for changing the course of the epidemic, if they are given the tools and support to do so. Initiatives that focus on marginalized groups are becoming increasingly important because they are particularly at risk if they are excluded from health services and exposed to unprotected sex at times in exchange for food, protection and money.
5.5.6 Conclusions The role modelling of the TCE staff on knowing your status has to be commended. It has helped the FOs to engage more effectively with the community and to mobilize them to go for VCT. The TCE intervention has significantly contributed to the acceptability of VCT and a majority of people seem to have either gone for a test or are prepared to undergo VCT. However, there is unfortunately no data to proof this, only anecdotal evidence. More in- depth research would be required to further look into this issue. The programme has also played an important role in increasing the acceptability of ARV treatment as well as access to ART, and adherence to ARV through being involved in treatment trios, facilitation of support groups of PLHIV, and defaulter tracing. Similarly, the programme also deserves commendation for its efforts to motivate pregnant women to take part in PMTCT efforts. The value added effect of the TCE programme for all these activities has been widely recognized by communities and key stakeholders in the areas. The programme has also contributed to making condoms more accessible, especially in remote rural areas, and de-sensitizing talking about and accessing condoms. Although there is some anecdotal information that condom use has increased, this would need to be further researched. Data from the National HIV testing day indicate
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considerable lower HIV prevalence levels than those of the 2006 HIV sero- prevalence study among pregnant women. However, it is not possible to draw any conclusions from this as the sample is not comparable. Second generation surveillance consisting of a combination of HIV and behavioural surveillance is unfortunately not in place in Namibia and can therefore not be used to measure real changes over time. DAPP/TCE is planning to do an end of project study to compare its baseline study data against; this will give —harder“ data regarding changes achieved than could be done during this qualitative evaluation.
5.6 Evolvement of programme and next phase
5.6.1 Establishment and visibility in communities The greatest advantage of the TCE programme is that it is very well established, visible and well known. All stake holders œ governor, councillor, traditional king, traditional head man, health workers, health managers and NGO staff interviewed were all very knowledgeable about TCE. They are in regular contact with the programme and have good working relations with TCE staff. Specific training of traditional leaders has also taken place under the CDC funded TCE programme for which also leaders from GFATM areas have been invited. TCE is also an active partner in RACOC meetings and is known to bring up issues that are flagged by community members. Various stakeholders referred to the TCE FOs as their —eyes“ for what is happening in communities. Examples of issues raised by TCE in RACOC meetings are e.g. problems regarding non functioning water taps, health outreach points who failed to make field visits and emerging food problems. Regional health facilities have used TCE FOs to effectively trace TB and ARV defaulters. TCE staff has also been used to address the cholera epidemic and rabies break out. The strong link with communities is widely appreciated.
TCE door-to-door clients, groups, passionates, patients in ARV treatment sites indicated to be well aware of the TCE programme. During a —quick scan“ in an ARV treatment centre with waiting patients, only two out of 14 people did not know the TCE programme. On further questioning it appeared that these two persons came from Angola.
The CDC funded TCE programme includes training of traditional leaders. However, in the current GF agreement there are no resources set aside for such training.
5.6.2 Passion for People Movement“ volunteers and FOs The TCE FOs try to mobilize a number of volunteers in their areas who can support them. These volunteers are called TCE passionates and obtain a yellow T-shirt with the TCE logo so that they can be easily recognized by community members. So far, out of the 700,000 people reached by the (GF funded) programme, over 35,000 are registered to have become passionates. However, many of these passionates are in fact not active anymore. Passionates may move out of the region, find jobs or have other reasons why they stop being active. The majority of passionates whom the evaluation team met were member of peer support groups. One passionate was part of an ARV support trio and another one was working in a car wash providing condoms and information to clients. The idea is that the passionates will continue with their work once the programme phases out. Passionates are therefore seen as a way to ensure the sustainability of the programme. It is questionable however for how long these passionates will continue without the active support of the Field Officers.
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It is anticipated that a number of Field Officers will not move on to other jobs once the programme stops, because of lack of job opportunities or because of other reasons. Field Officers in general are encouraged to continue activities once the programme stops. However, without active support one can ask with how much effort these FOs will be able to continue these activities. At the same time, a number of FOs, because of the training received and experience gained will now have a better opportunity to find alternative jobs. If they stay in the same community, they may be able to continue some activities, although it is unlikely that they will have much time to do so. .
5.6.3 Referral/drawing upon other resources The TCE programme is drawing upon resources of other players, which enhances the sustainability of the programme. The over 10,5 million condoms distributed so far, have all been made available by MoHSS. ARV treatment services are also being provided by MoHSS. VCT is accessed either through the New Start Centres or MoHSS facilities. In those areas where the Red Cross has a home-based care programme, TCE coordinates with the Red Cross volunteers. Several TCE FOs mentioned that Red Cross volunteers actively collaborated with the support groups set up by these FOs. TCE is able to draw upon CDC Namibia and MoHSS staff for teaching purposes.
5.6.4 Ready to move to next phase? All stakeholders interviewed said that they would like the programme to continue. The King of the Uukwambi tribe in Oshana mentioned that he would be willing to take it up with the Minister of Health. The Governor of Omusati Region said —This programme should continue to build capacity in the community because it helps to save lives, and now it needs to go deeper to reach the last person in the last village. The monitoring data shows that even after three years, weekly reports still show considerable numbers of people being newly registered. A closer look at household registry books of FOs revealed that among those registered substantial numbers of individuals have not yet not been met, especially men. Several stakeholders also indicated that it takes time for men to be brought on board. If efforts could focus on reaching out to those not yet reached in the same areas, most of which are densely populated , and if the communication/facilitation skills of FOs could be strengthened to also address drivers of the epidemic, the programme could be taken to the next level in which it works towards achieving massive behavioural change.
As indicated under section 5.5 it is hard to measure at this point in time the outcome and impact of the programme in terms of behavioural change in relation to HIV prevention and new incidence. However, the planned TCE end of project research through which baseline data could be compared with end of project data, could provide some useful information. The programme has been very effective in ensuring that more people know their HIV status, are on ARV and have participated in PMTCT programmes, and have increased access to condoms. However, as mentioned above, fewer men have been reached and still considerable numbers of people in the areas are yet to be reached. Continuing the programme in the same geographic areas in order to ensure full coverage, especially of men, ensuring that drivers of the epidemic are fully addressed, and putting a system (second generation surveillance) in place through which the outcome and impact of programmes could be measured, would seem to be a logical next step. Expansion of the TCE programme to other geographic areas in Namibia could also be considered as the TCE face-to- face approach is appropriate and useful.
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5.6.5 Issues still to be œ systematically - addressed 5.6.4.1 Concurrent multiple partnerships One major problem in Namibia is that multiple partners for men are condoned and even encouraged. Evidence conclusively has shown the significant role of multiple sexual relationships in exacerbating HIV transmission. Serial monogamy traps the virus within a single relationship for years or months, whereas as soon as one person in a network of concurrent relationships contracts HIV, everyone in the network is placed at risk especially women as it is biologically easier to transmit HIV from men to women, then from women to men. Without multiple sexual partnerships, the HIV epidemic in Namibia would likely to be less severe. By extension, partner reduction is the most obvious, yet paradoxically neglected approach to the prevention of HIV in Namibia.
5.6.4.2Transactional sex Although we did not explore the extent of transactional sexual relationships, it was mentioned on a few occasions that it is quite common among young women. However, these young women are particularly vulnerable to unsafe sexual activities within transactional sexual relationships due to their weaker bargaining position relative to their male partners. Young women tended to use their limited bargaining power to negotiate for higher economic gains instead of safe sexual practices increasing their risk for contracting HIV. In addition, it is reported that some families encourage young girls to engage in sexual activity for material gain, such as paying for school fees, buying food for the family and transportation. Since these young girls have little or no say as to when to have sex, they are likely to be coerced into having sex, when they are not ready. The problem is that this type of sexual abuse creates a distorted understanding of appropriate sexual behaviour and a deep sense of worthlessness in victims, which could lead to promiscuity, because teenagers are busy with identity formation and it is a time of self discovery and excitement. During this period they need to be loved and to love intensely. They need considerable caring and commitment in individual relationships. If the need for emotional gratification is not fulfilled, the person may develop an emotional gap which can place him/her in a disposition for a sexual relationship to fill that gap. Previous studies have shown that the need for sexual gratification among sexually active youth is high and therefore prone to contracting HIV.
5.6.4.3 Early sexual activity and Intergenerational sex In Namibia, adolescent premarital sexual activity is fairly common. More boys are sexually active and at a younger age compared to girls. The average age for first sexual encounter is 15 years and it is reported that about 25% of adolescents aged less than 15 years are sexually active. Girls are particularly at a higher risk as their sexual partners does not only include their age group peers, but —Sugar Daddies“, a colloquial expression for someone who is often significantly older. Many adolescent girls have sex with older men, who are more likely to be infected, compared to boys their age, and who might also be involved in other high risk relationships. This age-mixing phenomenon is a crucial factor in increasing STI and HIV infections among young people. If young girls were having sex with boys their age, the spread of infection among adolescents would not be as high. On the other hand, these men are expected to be more knowledgeable and experienced about sex, this makes it more difficult for them to admit ignorance, seek information on HIV and safe sexual practices or learn about sexuality. This has profound implications for HIV prevention activities. It is also clearer that many young girls have little or no say with regard to when to have sex and with whom, and this make them especially susceptible to contracting and spreading HIV/AIDS. It has also been shown elsewhere that early sexual intercourse is commonly associated with a higher number of lifetime sexual partners, and consequently a higher risk of
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contracting sexually transmitted infections. The voluntary delaying of sexual debut is of key importance in the prevention of sexually transmitted infections and promotion of long term health. It must be understood that with sexual lifestyles that often include early onset of sexual intercourse and subsequent serial monogamy, these children are placing themselves at a considerable risk of acquiring sexually transmitted diseases.
5.6.4.4 Self-worth among women and gender-based violence Women's HIV risk from HIV transmission in Namibia clearly is embedded in the context of gender relations and that this context has central implications for interpersonal relationship factors relevant to women's HIV. Cultural norms of womanhood in Namibia, place a high value on sexual innocence, passivity, virginity, and motherhood. As mentioned in previous sections, women and girls are not supposed to be knowledgeable about sex and generally have more limited access to relevant information and services in the country as previous studies have shown. They often, therefore, remain poorly informed about sex, sexuality and reproduction. Dominant feminine characteristics among these women are characterized by an ”over respect‘ of men and to relate to men in a submissive and obedient manner and such naiveté, ”over respect‘ and obedience to men may not sit well with the assertiveness, the planning and the sexual knowledge they need to ensure that their sexual encounters are safe. Men‘s preference for sexual control and initiative in Namibia would be less of a problem for HIV and STI transmission if this preference were for safe sex. While the pattern of male activity and female passivity is problematic in terms of feminist ideal of mutually initiated and egalitarian sexual relations, it raises problems for HIV transmission only in terms of men‘s reluctance to practice safe sex. In addition, the emphasis on male masculinity sanctions gender- based violence.
5.6.4.5 Male circumcision and other traditional practices Recent research with trials in a number of countries in Sub-Saharan Africa has shown that safe male circumcision reduces a man‘s chance of being infected by up to 60%. Now, there is a renewed effort to adopting this as part of a wide prevention package in Namibia. The recent Demographic and Health Survey, 2006 (DHS) indicate that about 21% of all men reported being circumcised, with higher circumcision rates of over 30% in Omaheke, Kunene, Kavango and Otjozondjupa). This is now believed to be the reason for the lower prevalence in communities were male circumcision is a cultural practice, such as in Omaheke and Kunene North. This is an opportunity for the TCE to devise strategies that encourages men to undergo circumcision and to work with the health services to promote universal access to circumcision for newly born babies. But, this should also be coupled with intensive work around some delirious cultural practices, such as dry sex and warming of the vagina, which are fairly common in some Namibian communities. —Dry sex“ is a practice where a woman‘s vaginal lubrication is removed with vaginal drying agents most commonly traditional herbs. There is a general belief among people that —dry vaginas that are swollen with friction are tighter, and this pleases the men because it makes them feel larger and they also find sex more pleasurable. It is also believed that many men are also in need of virgins and using drying agents creates the sense of virginity“. With the emergence of HIV, the role that these practices play in facilitating the transmission of HIV, has developed a new interest. These practices, although not well documented in Namibia, have the potential to put women, especially young girls, at risk of contracting HIV. Research has also found that with the practice of dry sex women may contract HIV in three ways: Firstly, the lack of lubricant results in lacerations in the vagina‘s delicate membrane tissue, making it easier for the lethal virus to enter. Secondly, the natural antiseptic lactobacilli that vaginal moisture contains aren‘t available to combat sexually transmitted infections. In addition,
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intravaginal substances may alter the vaginal pH which normally serves as a protective factor against HIV acquisition (Kun, 1998; Janneke et al, 1999 and Morar et al, 2003).
5.6.4.6 Alcohol and substance use Substance abuse is common among the people of Namibia. Substance abuse is the result of availability and accessibility of especially alcoholic drinks and coupled by the lack of other more healthy distractions for young people such as meaningful employment or college education. Drug and alcohol abuse exposes people to all sorts of risks including sexual abuse, and contraction of STIs including HIV. It also increases the likelihood of irresponsible sex. In addition, intoxication can distort judgment and weakens resistance to sexual overtures. In Namibia, it is shown that as high as 15% of adolescents under the age of 20 years are consuming alcohol. High substance abuse gives people a feeling of invincibility and power where neither exists and is therefore attractive. However, this false invincibility is the author of many social vices such as violence against women and children, rape and unprotected sex.
5.6.4.7 Men having sex with men Issues around Male Having Sex with Male (MSM) are not well documented in Namibia. A recent prevalence probe (purposive sampling among a much diversified group of 200 MSM) by The Rainbow Project showed that 15% of those MSM tested were HIV positive. 50% self-identified with the lesbian/gay/transgender community. Preliminary data of ongoing research by the Rainbow Project shows that the number of partners is relatively small. However, these findings also suggest that there are linkages with sexual networks of the opposite sex and little is known about the size and how extensively they overlap. The study also suggests that formal and informal modes of sex work are practiced among MSM. Because of ongoing discrimination encountered by MSM in Namibia, MSM have little access to information and health resources and therefore are particularly vulnerable to infection.
5.6.6 Conclusion It would seem to be too early for the programme to be phased out. A lot of significant milestones have been achieved, especially in relation to the uptake of VCT, ARV and PMTCT .However, it remains unclear whether HIV incidence has also dropped. The programme has been well set up, well managed, stakeholders and beneficiaries commend the approach used and requested unanimously for the programme to be continued. Taking the programme to the next level during which both more male involvement would be realized and drivers of the epidemic addressed, seems to be a good use of resources and could potentially make a very important contribution to HIV prevention in Namibia.
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6 Recommendations
6.1 Management and organization
6.1.1 Staffing and management structure While the current structure functions well, the management versus the implementation cost are quite high. Consideration could be given to whether a somewhat leaner structure could work without jeopardizing the quality of work and taking into consideration that the educational background of the majority of staff is quite low.
6.1.2 Acceptance of FOs by community Field Officers in general are well respected and their gender and age does not seem to make a difference in their functioning. Currently one third of the staff is male and two third is female. However, in order to work towards increased male involvement; consideration could be given to the recruitment of a higher number of male FOs, who could be involved in organizing i.e. —male only‘ activities.
6.1.3 Internal meetings Even though the current meetings are important for staff motivation, training and ensuring that project process data are correct, rationalizing the number of and participants in internal meetings especially towards the later stage of the campaign could possibly lead to better use of staff time and funds .
6.1.4 Staff turn over It is important that new incoming FOs are well trained from the onset of the work, which has incidentally not been the case. In the cases of time constraints, causing delays or making training impossible, more on the job training approaches could be considered through twinning of new FOs with experienced ones.
6.1.5 Finances The current management cost of the programme is high. Efforts should, therefore, be made to streamline the structure or possibly include specialized staff like data specialists to improve the analysis and use of data. This could reduce the overall cost per person reached or improve the wider benefit of the programme.
6.1.6 Monitoring and evaluation Although rich monitoring data is collected, it is not easily accessible. For instance, the system does not facilitates easy analysis of how many people reported to have been tested for HIV in a particular period, or how many men/women have been reached once, twice or thrice over a particular period, etc. It is recommended that a more robust database with improved analytical capabilities be put in place, so that more analysis can take place for programme planning purposes.
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6.2 Approaches
6.2.1 Door-to-door approach The door-to-door approach has been widely recognized as an effective approach to discuss sensitive issues. The door-to-door approach should continue but could be done in a more targeted fashion, i.e. placing a stronger emphasis on reaching men perhaps by changing the timing of the visits, visiting areas less reached in the past, and focusing on specific age groups reached less during previous visits.
6.2.2 Number of people still being registered (first time contacts) in 2008 The FOs collectively have been able to reach 100,000 people more than originally planned (694,000 reached versus 580,000 planned). Understandably, this has implications for the frequency with which people have been reached, with beneficiaries reached only 2 œ 3 times on average instead of the anticipated 3 œ 6 times. Furthermore, substantial numbers of people in the areas covered with support from GF have not been reached, with ongoing new registrations still taking place. High population movement and the earlier underestimation of the number of people resident in these areas, may explain this continued flux of people to the TCE programme. Extension of the campaign in these areas, where nearly half of the Namibian population live, seems therefore appropriate.
The majority of people reached are female. It is recommended that TCE attempts to increase male involvement through i.e. regular male only workshops/conferences and specific activities targeted at men during Christmas when many men return home from the South, while at the same time promoting the notion that the society must encourage the commitment of both men and women to save the lives of their people.
6.2.3 Peer Support Groups Many support groups have started in different locations facilitated by the FOs. The support group members have often been able to provide valuable support to each other. However, respondents indicated that for a support group to function well, income generation activities were found to be important. More technical assistance should be made available to ensure that the income generation activities undertaken are viable.
6.2.4 Vulnerable groups More concerted action to reach out to vulnerable groups either through group activities, or door-to-door activities should be explored.
6.3 Tools used
6.3.1 Tools for door-to-door outreach Tools that help FO engage in discussions on why concurrent partnerships are especially conducive to the spread of HIV, male circumcision, safer sex options, sexual identify/MSM, transactional sex, alcohol use, etc. should be developed. Further training on how to use PES as a discussion tool that facilitates more in - depth discussion instead of an examination tool would also be useful.
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6.3.2 TCE Compliant While the compliance concept is clear within TCE, the people within the communities interviewed could not express the concept to the evaluators. Although the compliant concept in itself is a very good idea, it only works if people better understand what it means. During follow up visits, reference needs to be made to the compliance concept to reinforce the idea/concept.
6.4 Capacity Development and supervision
6.4.1 Training of staff Efforts should be made to ensure that FOs finish their training early on the job. The same person(s) at division level should be in charge of training throughout project. Recruitment practices for Special Forces should be reconsidered. It may be more beneficial to recruit Special Forces with the right educational background for the specialization required. Special Forces would then be able to operate more effectively œ including making arrangements with other key stakeholders for training and other purposes which is now often done through higher management.
6.5 Quality assurance/support to FOs Field monitoring looks among others at the quality of the work of the FOs. Special Forces at troop level, who have moved on from being a FOs to a Special Force position could be better trained on how to observe the activities in the field in order to support the FOs better.
6.5.1 Skills mix of FOs Efforts at finding ways to promote more cross-fertilization of ideas between FOs could be beneficial for the programme. E.g. FOs with successful experience in setting up a peer support group, good skills in running education sessions in cuca-shops or recruiting, training and retaining passionates could work closely together for a week or two with another FO who lack those skills. Currently, such information is only shared at troop meetings, but more hands-on exchanges in the field might be more beneficial.
6.5.2 Training modules The training manuals need to be redesigned and adapted to the Namibian context. The different training models could be combined so that the training becomes more holistic and focuses better on the tasks of the FOs, their skills required and the outputs, outcomes and impact to be achieved by the programme. It has been recognized that most of the drivers of the epidemic in Namibia were yet to be identified at the start of the TCE programme. However, it is strongly recommended that materials and tools for FOs should be developed to address these drivers as this will greatly help prevention efforts.
6.6 Effectiveness of the interventions and changes observed
6.6.1 Role modelling œ knowing your status and being open about it The œknowing your status- role modelling has had a positive effect for the project as a whole and has to be applauded. TCE should continue this approach for new staff. The formation of support groups for staff beyond division two should be considered.
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6.6.2 Uptake VCT, ART, and PMTCT The programme has strongly contributed to the uptake of VCT, ART and PMTCT. It seems important that these activities continue, especially since the level of stigma around HIV and AIDS is still significant, and much encouragement still needed for people to access treatment.
6.6.3 Condom distribution and use The TCE programme has been instrumental in increasing the accessibility of condoms at community level by establishing condom outlets in many areas far from clinics, training outlet owners in condom demonstrations and securing a regular supply of condoms via MOHSS. The condom demonstrations have helped people to become more skilled in the proper use of condoms. It is important that these activities continue. It is also important to explore the possibility of increasing the number of condoms to be distributed. This system should be maintained in the communities to secure easy access to condoms at the local level.
Anecdotal data shows that condom uptake and use has increased in the communities. However, more robust data would be needed to confirm this. The major gap of the TCE programme, however, is that it focuses more on general HIV education than on behaviour change that addresses underlying factors that lead men and women to take risk. It is critical that TCE embarks on the use of participatory approaches which challenges communities to confront, reflect on, develop their own responses to, and build their own normative consensus concerning sexual values and practises.
6.6.4 Stigma, discrimination and general perception of HIV TCE has played an important role in increasing acceptance of PLWHIV. In spite of this, stigma and discrimination by others as well as self-stigma is still considerable. Very few people in the communities are open about their status. Even people living in the same is that the right word ? compound, do not talk to each other about being infected although there seems an interest in being able to do so. TCE is to be commended that it has been able to motivate its entire staff to go for VCT. However, much more work needs to be done on helping people in the communities to open up about their HIV status. Discussions on the negative impact of stigma are also much needed. Strategies involving PLHIV who are open about their status at all levels of the programme will be important for this.
6.7 Evolvement of programme and next phase
6.7.1 Establishment and visibility in communities TCE‘s work has been very well recognized and its ability to reach out to people in remote areas applauded. Using this recognition, as a leverage in a further effort to turn the epidemic around through extending the programme should be considered.
Training of traditional leaders should be considered for GF funded TCE areas, as with TCE programmes in CDC funded areas. The training/meetings could focus on the development of strategies to increase male involvement (e.g. male only meetings with traditional leaders).
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6.7.2 Passion for People Movement“ volunteers and FOs TCE has been able to mobilize a high number of passionates. However, it would be good if TCE could review how many passionates have been really active for a longer period of time and who contributes to certain action when needed. The yellow T-shirts provided to the passionates seems to have been a good move, as people are really proud of them and seen as a reference point in the community. This has further increased the visibility of the programme. In the next phase, more yellow T-shirts should be budgeted for as not all passionates have received such a T-shirt. More in-dept communication training for those passionates engaged in providing information on HIV could improve their effectiveness.
6.7.3 Referral/drawing upon other resources TCE is drawing upon resources of other players, which enhances the sustainability of the programme and has to be commended. Further collaboration for e.g. more intensive coverage of OVCs should be considered.
6.7.4 Ready to move to next phase? It is recommended that funding for a two year extension should be made available for the TCE programme in the areas currently covered with GF support. During these two years much emphasis should go to reach individuals not yet reached, especially men. Process data show that after nearly three years, still considerable people are newly registered every week and that people on average have not had sufficient exposure to the programme. Especially men have not been fully reached as it takes time to get them on board. Different strategies to reach men could be used, e.g. involving headmen in meetings for men only, sports activities, special actions around Christmas for returning migrants, etc.
In addition, the major focus should be on building the communication/facilitation skills of FOs to effectively work with behavioural change activities around concurrent partnerships, transactional sex, early sexual activity and intergenerational sex, gender and violence, male circumcision and cultural sexual practises, alcohol use, MSM, etc. This should be implemented with specially developed face-to-face communication tools.
The evaluators also believe that it would be appropriate and useful to expand the TCE face-to-face approach to other regions in Namibia. This would also help to target those who move from the North to the centre or the south of the country in search for jobs. In an improved and updated version with the recommended training and tools to address the drivers of the epidemic, TCE could act as catalyst for more people to benefit from health and other related services. This is in addition to the building of the capacity in communities to deal with the consequences of the HIV epidemic.
6.7.5 Issues still to be addressed: 6.6.4.1 Concurrent multiple partnerships Because of the evidence that multiple sexual relationships are very conducive for rapid HIV transmission, partner reduction should be the centrepiece of an unified approach:
6.6.4.2 Transactional sex The one-to-one discussions should discuss underlying reasons for transactional sex, both with men and women, and explore a range of options for HIV risk reduction with those involved in transactional sex.
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6.6.4.3 Early sexual activity and Intergenerational sex TCE intervention should focus more of their attention on delaying sexual debut for the younger members of the household. Although condoms reduce the transmission of discharge related infections such as HIV, it is not enough to only promote the use of condoms among young people, without focusing on delayed sexual debut. The present relationship between early sexual activity and an increased number of sexual partners shows a need for more work on motivating and empowering youth to delay their sexual debut. However, care should be taken that this is done without moral judgement as not to discourage those youth who do become sexually active at an early age to use a condom.
6.6.4.4 Self-worth among women and gender-based violence Because gender has become convoluted and synonymous with women, addressing gender issues is challenging for partners like TCE. The concept of gender has become confused also at grass roots level, where this concept needs to be widely understood in the context of HIV. Interventions on HIV being implemented by TCE should not address gender issues generically without understanding the underlying factors. Efforts are needed to develop and implement evidence based strategies that empower both men and women to effectively address HIV.
6.6.4.5 Male circumcision and other traditional practices It is important that the TCE programme develops a better understanding of the context and meaning of sexual traditional practices for the community and to develop better strategies to help mitigate the negative effects of these practices.
6.6.4.6 Alcohol and substance use It is recommended that as the programme embarks on TCE Phase II, it includes activities around people‘s understanding of the impact of alcohol.
6.6.4.7 Men having sex with men Because of ongoing discrimination encountered by MSM in Namibia, they still have little access to information and health resources and as result are particularly vulnerable to infection. Therefore, the tools used during TCE Phase II should address issues around MSM.
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ANNEXES
DAPPœTCE Programme Evaluation | May/June 2008 37
38 DAPPœTCE Programme Evaluation | May/June 2008
Annex A: DAPP œ TCE Programme Evaluation Schedule
Day Location Person(s) met/interviewed Topics discussed/activities 20 May Windhoek • Preparation evaluation Tuesday • Claire Dillavou, SI/M&E Advisor, CDC • Coordination between mid-term review Namibia CDC and evaluation 21 May Windhoek • Evaluation preparation (tools, Wednesday methodology, review key documents, etc) • Kirsten Moeller Jensen, Managing • Agreement TOR, schedule/logistics, Director DAPP capacity building, documentation and • Alfred Besa, Project Coordinator TCE interview
22 May Windhoek • Pamela Onyonga, Program Director • TOR, documentation, meeting Thursday PMU/GF - MOHSS schedule, feedback meeting/report., • Uche Nwokenna, Manager M&E, instruments, and interview PMU/GF - MOHSS Travel to Ongwediva 23 May Ongwediva • Alfred Besa, Project Coordinator TCE • Review schedule, overall monitoring Friday (travel to • Judith Kambimbi, Special Force data, organizational structure, TCE different (coordinator training) compliance. locations in • Oscar Shiweva, Deputy Corps • Interviews in between meetings with Omusati) Commander (M&E coordinator) Judith Kambimbi, SP and and Oscar Shiweda, DCC in the car.
• Field Officers (100), troop • 2 parallel troop meetings commanders, division commanders, PR (approximately 55 -60 persons per officer (Abel Ngato), etc. in Omusati meeting).
• F.O. and mother and daughter (TCE • Door-to-door visit with F.O. to female compliant) in rural area Omusati headed household in rural area Omusati (observation and interview)
• Cuca shop owner • Smile condom outlet stocked by TCE F.O. (interview/condom demonstration) 24 May Ongwediva • Melody Chipadze, Division 1 • Visit to TCE office in Omusati Saturday (travel to Commander • Interviews in between meetings with different Melody Chipadze, Commander locations in Division 1 and Oscar Shiweda, Deputy Omusati) Corps Commander in the car. • Rebekka, F.O. in Ogongo, Omusati • FGD with TCE passionates in Ogongo, • TCE passionates: Siama, Selma, Omusati Ilonga, Dapankula • Role play - HIV negative counselling • Mother and son in rural area • Door-to-door visit in rural area Ogongo, Omusati (2 houses) (observation) 25 May Ongwediva (Sunday: Review documentation, further Sunday development tools, write up interviews) 26 May Ongwediva (National Holiday: Review documentation, Monday further development tools, preparation evaluation capacity building workshop for TCE) 27 May Ongwediva • Hon. Sackaria Kayone, Regional • Meeting with the Regional Governor of Tuesday (travel to Governor Omusati region, Outap Omusati (Chair of the RACOC) different • Aktofel Shikango, Personal Asst (interview) locations in Governor • Interviews in between meetings with Omusati) Melody Chipadze, Commander Division 1 and Oscar Shiweda, Deputy Corps Commander in the car • Hon. Tataati Simon Sileka, Outapi • Meeting with the Outapi Councillor Constituency Councillor (interview)
DAPPœTCE Programme Evaluation | May/June 2008 39
Day Location Person(s) met/interviewed Topics discussed/activities • Hilda Iipinge, Director of Health, • Meeting/interview with Director of Omusati Region Health and Chief Medical Officer for • Dr. Anni-Liina Hatutale, Chief Medical Omusati region Officer, Omusati region
• Shuuya Lokas, Administrator DAPP • Visit to New Start Center in Outapi New Start Center in Outapi (Interview) • Dr. Miriam Makanje, CDC Outapi • Visit to CDC/ARV Clinic in Outapi • Joanna Mashilongo, Nurse (interview/quick scan) • Around 15 patients on ARV treatment
• Martha Aipanda, F.O. • Visit to Oshikulutitu Support Group œ • David S. Advisor support group Youth Center (FGD) • Luisia T. Member support group Steramarcha, Deputy chairperson support group • Nastasia, Member support group • Magdalena, Chairperson support group • Suwama, Secretary support group • Lidia, Member support group • Magdalena, Advisor support group
28 May Ongwediva • Kirsten Moeller Jensen, Managing • Evaluation Capacity Development Wednesday (travel to Director DAPP Workshop (3 hours) œ Ongwediva different • Alfred Besa, Project Coordinator TCE DAPP office locations in Programme Oshana region) • Oscar Shiweva, Deputy Corps Commander (M&E coordinator) • Melody Chipadze, DC Division 1 • Oswin Sindigi, TC Omusati • Abel Ngato, P.R. Officer • Damiana Conde, Division 2 Commander • Apollonia Negumbo, Special Force M&E • John Shikongo, Division 2, M&E
• Karolina Shiyagaya, Senior Health • Meeting/interview MoHSS Regional Programme Administrator for Special Office Oshana Programmes, Regional Office MoHSS, • Interviews in between meetings with Oshana Region Melody Chipadze, Commander and Oscar Shiweda in the car • Hon Herman Ekumbo, King Uukwambi • Meeting/interview with King Osvambo œ Uukwambi tribe • Beatus Shiwetheleli, Special Force, • FGD Okatana Patrol Division 1, Troop 2 • Role Play • Linus Betrus, F.O. • Trend analysis • Diamond Katola, Passionate • Beata Natina, F.O. • Thyme Alonga, F.O. • Abraham Owendo, F.O. • Christofina F.O. • Epatras, F.O. • Hambelekin, F.O. • Christiana Simon, F.O.
• Basilius Kaseia, Site Manager, New • Meeting/interview site manager New Start Center Start Center in Oshana, Catholic Action Aid (CAA)
29 May Ongwediva • Damiana Conde, Divison 2 Commander • DAPP Office in Ondangwa & interview Thursday (Travel to • Alfred Besa, Project Coordinator TCE in car different areas in • Interviews in between meetings with Ohagwena Damiana Conde, Division 2 region) Commander and Alfred Besa, Project Coordinator TCE in the car
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Day Location Person(s) met/interviewed Topics discussed/activities • Toivo Amtoko, F.O. • Focus Group Discussion Field Officers • Joolokeni Mufeni, F.O. Troop 1 & 2 Division 2 • Tueni Nanjemba, F.O. • Trend analysis • Hailonga Felipus, F.O. • Isaac Namapara, SF
• Maria Nujoma • Focus Group Discussion Support • Louisa Heita Group members • Hilma Shimbi • Sara Nekombo • Selma Nehonga
• Wendy Lilongwa, Red Cross • Red Cross, Ohangwena Region (interview) • Dr. K.J.Y. Kashaija, Public Health • Engela Regional Hospital (interview) Specialist • Abraham, Special Force (Field and area • Observation door-to-door visit and and PR) interview with 25 yr old door-to-door • Elize Shilongo, F.O. client • Ottili (25), Client door-to-door visit
30 May Ongwediva • Informal discussions/FGD discussions • Observation, review household Friday (Travel to with approximately 10 F.O. of Division register, daily activity register and different areas in 2, troop 2 informal FGD with F.O. during Division Ohagwena 2, troop meeting region) • Interviews in between meetings with Damiana Conde, Division 2 Commander and Alfred Besa, Project Coordinator TCE in the car • Heindrich Shihenuka, Headman, • Interview headman Onangama Onangama (village level)
• Paolo Gotri, F.O. • Door-to-door visit. Observation PES (1 • Maria Hambingwa (25), Client door-to- person) followed by interview with two door visit door-to-door clients. • Paavo (23), Client door-to-door visit
31 May Ongwediva • Jozef Philemon, Passionate • Interviews in between meetings with Saturday (travel to Damina Conde, Division 2 Commander different and Oscar Shiweda in the car locations in • Interview with Passionate who Oshikoto region provides HIV information and condoms to clients in his car wash
• Louisa Kasheeta, F.O. Division 2, • FGD in cuca shop following a HIV Troop 1, Patrol 2. session by Louisa Kasheeta, Field • 9 persons (2 men and 7 women) in a Officer cuca shop
• Hilja, Special Force, Division 2. • Interview in car re the People Passion Coordinator People Passion Movement Movement income generating activities • Josephine Sehja Onyanga, Field Officer • Observation outreach session (last • 8 persons (3 men and 5 women) in a part) by F.O. in Cuca shop followed by cuca shop FGD with the people in the cuca shop.
• Matzi Maria, door-to-door client of • Interview with door-to-door client Josephine Sehia Onyanga, F.O.
1 June Ongwediva (Sunday: Review project and other Sunday documents and report preparation)
DAPPœTCE Programme Evaluation | May/June 2008 41
Day Location Person(s) met/interviewed Topics discussed/activities 2 June Ongwediva • Division 2 DCCC meetingœ Division • Observation (part of) DCCC meeting Monday (travel to Commander, Deputy Division and discussion re. weekly results different Commander, Troop Commanders (4), presented locations in Development Instructors (4), Special Oshikoto Forces (around 14)
• Mascha Greuling, Development • Interview Development Instructors Instructor • Naomi Mortimer, Development Instructor
• Taitus, Troop 2 Commander • Interview Troop Commanders • Teresia, Troop 1 Commander
• Frieda, Field Officer • Observation PES and interview door- • Naomi Napuka, door-to-door client to-door client
• Louisa Kasheeta, Field Officer • Interview Trio member • Paulina N. Angula, Trio member 3 June Return from • Travel Tuesday Ongwediva to • Report writing/debrief preparation Windhoek 4 June Windhoek • Report writing/debriefing preparation Wednesday 5 June Windhoek • Report writing Thursday 6 June Windhoek • Dr. M. Goraseb, DD, DSP, MoHSS • Debrief MoHSS/GFATM PMU Friday • Sarah Tobias, STI & Condom Promotion Coordinator, DSP, MoHSS • Wilhelmina Kafitha, SHPA Palliative Care, DSP, MoHSS • Timea Nuwira, Combi Manager (HIV/AIDS) MoHSS/UNFPA • H.Y Ipinge, TB Coordinator GF/MoHSS • M. Manyando, HBC œ PHC, MoHSS • R. Mahalie, PMU/GF • J. Ntiuda, PMU/GF
• Kirsten Moeller Jensen, Managing • Debrief DAPP TCE Director DAPP • Alfred Besa, Project Coordinator TCE
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ANNEX B: List of documents reviewed
DAPP FO Case studies (approximately 14 case studies)
DAPP TCE Namibia, April 2004. Baseline Survey Report: Omusati-TCE Area 4
DAPP TCE Namibia, June 2004. Baseline Survey Report: Oshana-TCE Area 1
DAPP-TCE Namibia. Field Officer Initial Training Manual
DAPP. The TCE Field Officer as a Counsellor. Diploma TCE Studies
DAPP. The TCE Field Officer as an Educator, Diploma TCE Studies
DAPP TCE. What to strive for during 3 years of TCE
DAPP TCE Namibia. GF monitoring data
DAPP TCE Namibia. Job Descriptions
DAPP TCE Namibia. Manuals for FOs and TCs.
DAPP TCE Namibia. Field visit reports
Enterprise Development Intelligence (EDI). February 2006. Total Community Mobilisation- The TCM HIV/AIDS Programme in Botswana. Evaluation report
Global Fund Agreement. Draft Project Grant Agreement under the Namibian Global Fund Programme between MoHSS and DAPP
Iipine, S et al, 2007(?) The Comprehensive Care and Support for PLWHA and/or Chronically III patients. Global Fund Evaluation Report
MoHSS October 2003. Namibia Demograpic and Health Survey 2000
MoHSS. 2008. Namibia Demographic and Health Survey 2006/7 (unpublished)
MoHSS 2006. Progress report on the Third Medium Term Plan on HIV/AIDS. April 2004 -31 March 2006
MoHSS 2007. Progress report on the Third Medium Term Plan on HIV/AIDS for the period April 2006 œ March 2007
MoHSS. 2007. Report of the 2006 National HIV Sentinel Survey: HIV prevalence rate in pregnant women, biannual surveys 1992 œ 2006, Namibia.
MoHSS 2008. National TB and HIV Targets. Final Report.
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Annex C: Data Collection Instrument
Data collection tools
Type of Type of Tools respondent interaction DAPP Interviews Interview guidelines Management • Duration involvement DAPP/TCE? (various levels) • Reason of working with DAPP/TCE? • Training received/qualification/previous work experience? • Proud of? Value added of TCE? • (Management) challenges?
• Linkages & coordination other organizations (incl. RACOC/CACOC, traditional leaders) • Length of three years campaign strategy? • Selection programming areas? • Feasibility TCE programme in less populated areas? • Field Officers – selection criteria, training, turn over, effectiveness in field, sex ratio, etc. • Overall staff capacity? • Relevance training curriculum? • M& E data system and use?
• Data analysis? • Program outcome/impact? (Specific examples – behavioural change, VCT, ARV, PMTCT) • HIV prevention challenges? • Meaning TCE compliance? • If start again, what done differently? DAPP Field Interviews Interview guidelines Officers • F.O. since when? • Educational background? • Training received, # of trainings, content • Like and dislike about work? Challenges? • Understanding TCE concept? • Meaning of TCE compliance? • Example setting through own modified behaviour (i.e. VCT)? • M&E data (log book, use of data, target per week)? • Overview of activities per week and time spend per activity? • Outcome, impact changes observed (Behavioural change, VCT, ARV, PMTCT)? • Knowledge of state of epidemic in specific area? • Feasible of door-to-door concept in areas where people are scattered? • If start again, what done differently?
Focus group FGD guidelines discussions • Understanding TCE concept? • Meaning of TCE compliance? • Outcome, impact changes observed? • Challenges for behavioural change (gender inequality, alcohol use, state of epidemic, migration, concurrent partnerships, etc.) • Staff turn-over ? • Staff capacity? (incl. training provided) • Example setting of own behaviour (VCT Experience?)? • Feasible of door-to-door concept in areas where people are scattered? • Possible improvements to programme?
Role plays Role play guidelines • Request F.O. to role play a specific interaction with a client. Situation 1: A person has obtained his/her HIV testing results from a VCT center and learned he/she is HIV negative. The F.O. meets with him/her a few days later and discusses a strategy to remain HIV negative.
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• Situation 2: A FO meets with a pregnant women and advises her about PMTCT options. • Other situations may be used picking up on issues brought up during the interviews.
Site visits Site visits • Observe process of door-to-door visits and club meetings in different locations. Issues to be looked into: relationship established, dealing with difficult issues (gender inequality, alcohol use, concurrent partnerships, access to services (condoms, VCT, ARVs, PLHIV peer support group), reached by other organizations/activities, etc. Stakeholders Interviews Interview guidelines • In contact with DAPP/TCE since when? Regional level: • Knowledge of DAPP/TCE activities? RACOC, • Added value TCE/difference if TCE would not have been in area? CBOs, PLHIV • Likely to happen when TCE stops? • Coordination with various organizations, including TCE? support • Uptake services – VCT, ARV, PMTCT, condoms, PLHIV peer support groups, NGOs groups, Income generating groups, etc. • Data availability on uptake services? Community • Noticed any differences in region? (Possible influence TCE?) level: CACOCs, CBOs, community/tra ditional leaders, PLHIV groups, groups organized by DAPP Individuals/ Interviews/F Interview guidelines Families GD • First contact TCE? reached by • Frequency contact? programme • # of FO over time and differences per FO? • In contact with other organizations (Red Cross, CAA, Elcin, etc.) ? • Difference these other organizations and TCE? (probe about door-to-door approach) • TCE talked about in community? What, when, by whom? • Knowledge about HIV prevalence in area? • Know PLHIV? • Talk to others about HIV? With whom, about what? • Perspective on HIV? • Access to VCT, ARV, PMTCT, condoms, • HIV prevention, how? • TCE compliant? Why? Meaning?
Trend Trend appraisal guidelines appraisal • Ask family to remember the HIV situation 3 years ago • Ask them to describe the situation of 3 years ago (3 – 5 indicators i.e. stigma, people dying, no access to ARV, VCT, condoms, people not talking about condoms, etc.) • Ask them to describe the situation now (3 – 5 indicators • What has caused these changes? • What is likely to happen in the future? • What further changes are needed to stop HIV from spreading? Case study Case study guidelines (approximat • Based on trend appraisal exercise, select individual/family to describe ely 1 per their situation more in-dept re changes over time. region) Story with Story with gap guidelines gap • Show a before and after picture. (Before: a man in the community. After: same man visiting a VCT center)
DAPPœTCE Programme Evaluation | May/June 2008 45
• Ask individual/family to describe the two pictures. • Give them a few minutes to think about what happened in between picture 1 and 2. • Ask them to tell the story? • Ask follow up questions. (i.e. why would the man have gone, who would have motivated him, what will he do with the results? If he test negative, how could he stay negative? Etc.
Individuals/ Interviews Interview guidelines families not • Approached before by TCE staff? (When, frequency?) participating in • Reason for not participating? programme Passionates FGD • Involvement with TCE since when? • Why passionates? • Activities? • Interaction field officer? • Role passionates when programme stops? Role play • Interaction at community level – pick up on an activity they said to have been involved in Community AIDS trend Trend appraisal guidelines groups/clubs appraisal • Ask family to remember the HIV situation 3 years ago organized by • Ask them to describe the situation of 3 years ago (3 – 5 indicators i.e. TCE stigma, people dying, no access to ARV, VCT, condoms, people not talking about condoms, etc.) • Ask them to describe the situation now (3 – 5 indicators • What has caused these changes? • What is likely to happen in the future? • What further changes are needed to stop HIV from spreading? Transmissio Conduct Transmission Life Skills activity (modes of transmission, why of n Life Skills transmission). activity FGD FGD guidelines • -First contact TCE? • Frequency contact? • # of FO over time and differences per FO? • In contact with other organizations (currently and before) • Difference these other organizations and TCE? • TCE talked about in community? What, when, by whom? • Knowledge about HIV prevalence in area? • Know PLHIV? • Talk to others about HIV? With whom, about what? • Perspective on HIV? • Access to VCT, ARV, PMTCT, condoms, • HIV prevention, how? • TCE compliant? Why? Meaning?
Service Interviews Interview guidelines providers • Collaboration TCE? (PMTCT, ARV, • Collaboration other organizations? VCT) • # people referred by TCE • Difference people referred by TCE and others? • Client load over time? Last month? • What would happen in TCE stops? • Recommendations for TCE?
ARV, PMTCT, Interviews Interview guidelines VCT clients • How do you know of this service? • Interaction TCE? • Influence of interaction on making use of service?
Condom Interviews – Guidelines:
46 DAPPœTCE Programme Evaluation | May/June 2008 outlets observation • Condom turn-over ? • Who and frequency of supply? • Added value of supply of condoms in outlet? • Complaints about condom breakage or slippage? (other info on use?) • Condom demonstration?
Other info Analysis framework sources – • Comparison data in regions where TCE works – three years ago and now M&E data, • Comparison data in regions where does/doesn’t work project documents and surveillance/D HS, VCT data (different regions for comparison)
DAPPœTCE Programme Evaluation | May/June 2008 47
Annex D: TOR for the Evaluation of DAPP TCE programme
1. Introduction and background
DAPP Namibia is registered as a welfare organisation under the Ministry of Health and Social Services in Namibia. It is a co-founder and member of the Federation of Associations connected to the International Humana People to People Movement. DAPP Namibia is receiving technical support from Humana People to People. DAPP Namibia has been in operation since Namibia’s independence. The aim of the organisation is to fight poverty, illiteracy, HIV/AIDS and to work with the people towards the development of Namibia. DAPP Namibia is a sub-recipient of the Country Coordinated Global Fund for Namibia to fight HIV/AIDS, TB and Malaria.
DAPP Namibia is presently running 5 project types that include DAPP Child Aid & Environment Project with 10 lines of community development activities in Omusati, Ohangwena, Oshikoto and Kavango region, DAPP Vocational Training School, DAPP Private School, New Start Centre in Omusati region, and TCE in Omusati, Oshana, Ohangwena, Oshikoto Kavango, Caprivi and Khomas regions.
TCE is an innovative grassroots, one-on-one communication and mobilization strategy for prevention of HIV/AIDS and behavior change that has been implemented in several countries in Southern Africa. It is based on the idea that “Only the people can liberate themselves from HIV/AIDS - the epidemic” and that every person has to be reached with information, education, counselling and mobilization to take control of HIV/AIDS in his or her life.
DAPP Namibia has been implementing the TCE program in 9 TCE areas (a TCE area = 100.000 people) in Omusati, Oshana, Ohangwena, Oshikoto and Kavango Regions, employing 450 Field Officers. Six TCE areas are funded by MOHSS/Global Fund and three TCE areas are funded by the CDC (Centre for Disease Control in Namibia).Lately TCE is also implemented in another 3 areas in Kavango, Caprivi and Khomas making the total number of areas 12, targeting 1.2 million people.
The goal of the TCE programme is to mobilize the community in each TCE area to take control of the epidemic through a one-on-one approach. The 290 Field Officers employed in the MOHSS/Global Fund funded areas have been going from house to house and conducting person-to-person comprehensive prevention campaigns, counseling, mobilizing, and reaching each and every family member during a 3 year campaign. This three year campaigning is now coming to an end and hence this evaluation.
2. Purpose of the evaluation
The purpose of the evaluation is to assist DAPP by providing information about any needed adjustment of objectives, policies, implementation strategies, as well as providing information if and how donor funding should be continued. The Global Fund has also called for this evaluation as part of its monitoring processes and it is intended to provide an indication of the implementation processes of the agreed upon project, the
48 DAPPœTCE Programme Evaluation | May/June 2008 impact of the project and to ensure that a clear understanding emerges as to the manner of a continued relationship between DAPP and the Global Fund. The evaluation will be limited to the TCE activities funded by the Global Fund. Effort will be made to coordinate this “end of project” evaluation with a “mid term evaluation” conducted by CDC Namibia for the three by CDC supported TCE areas in Kavango, Ohangwena and Oshikoto.
2.1 Objectives More broadly the evaluation will aim to answer the following questions: i. How efficient and effective have the implementation strategies of the TCE programme been to reach its objectives? ii. How many people have been reached through which activity and what has been the frequency of the interaction with the different activities? iii. Has the programme provided individuals, households and/or communities with knowledge, skills, motivation and an enabling environment resulting in increased care and treatment seeking behaviour and reduced HIV transmission risk? iv. How sustainable is what has been put in place by the programme? Is the programme ready to evolve to the next phase where the door-to-door approach of reaching all individuals is replaced by a targeted approach for a selected group of individuals?
3. Methodology The evaluation, which will use a participatory approach, will be undertaken in consultation with DAPP, MoHSS and the Global Fund PMU. The following steps will be used to develop and implement the evaluation. The two member evaluation team consisting of a KIT staff member and a NEDICO staff member will firstly review selected documents (including programme monitoring data), develop appropriate data collection tools and set a work plan to accomplish the tasks. These data collection tools and work plan will be developed in consultation and collaboration with DAPP. One or two staff members of DAPP will also participate in the evaluation process. At the onset of the evaluation, the evaluation team will also conduct a three hour workshop to take key DAPP staff through the steps of an evaluation process to provide them with basic evaluation skills.
The evaluation team will undertake a wide consultation with DAPP staff at both office and field levels, RACOC/CACOC, community members, NGO representatives, service providers, households and individuals reached and not reached by the programme. For this consultation, a range of different methodologies will be used:
• Focus Group Discussions with DAPP Field Officers/Management , individuals/households, club members, PLHIV peer support groups reached by TCE and RACOC/CACOCs members. • Indept interviews with key stake holders (Governors, traditional/community leaders, service providers, etc) and people reached by TCE and those not reached. • Role plays to review interaction of DAPP Field Officer staff with individuals, household and communities. • Case studies to describe a few (two-three) specific cases
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• Trend appraisal by households/group members to analyse changes over time (onset of TCE programme versus now). • Story with a gap to obtain insight in issues relevant for individuals/households • Lifeskills activity for club members to obtain insight in communication skills in relation to HIV • Review of different programme reporting systems. • Review of training materials for DAPP staff, etcetera. • Review of DHS/Sero surveillance, VCT, ARV, PMTC update take in the TCE and non TCE areas.
Particular attention will be paid to the development of appropriate tools for use with households and individuals reached by TCE. The assessment and data collection tools, and the work plan will be presented to DAPP for approval. The data collection tools will also be shared with the GF PMU who in turn will share these with CDC Namibia.
The sites to be visited in Omusati, Oshana, Ohangwena and Oshikoto will be decided upon in consultation with DAPP. Effort will be made to visit an as wide range of activities and talk to a diverse range of persons as possible.
4. Timeframe The DAPP-TCE programme implementation cycle ends in August 2008. As it is important that the evaluation will be carried out just before this time, the evaluation will take place between May 20 and June 6.
5. Deliverables A detailed report addressing the objectives of this terms of reference will be prepared by the evaluation team. In addition this report should: • Formulate the major strengths and weaknesses, opportunities and threats of the programme(s) and relate these to the policy/development approach HUMANA People to People • Draw conclusions and state whether the organisation and its programme is suitable for further funding, and if so, on what conditions. Formulate some possible scenarios for further funding as well as future cooperation with the Global Fund. • Also of importance is to address the phasing-out strategy and how best this could be done • Advise the organisation on change/improvement if it is considered appropriate for further (financial) support.
The draft report will be submitted to DAPP for comments tentatively on June 6 but at the latest on June 26. Depending on the date of submission DAPP will provide feedback on June 12 or July 2. Following the integration of DAPP comments, the 2nd draft will be shared with DAPP and the Global Fund PMU.
50 DAPPœTCE Programme Evaluation | May/June 2008