7

PEPFAR’s Orphans and Other Vulnerable Children Category

Summary of Key Findings

  • As of September 30, 2006, PEPFAR had provided services to more than 2 million orphans and other vulnerable children in the focus countries. There is no specific performance target for the number of orphans and other vulnerable children to be served, instead they are counted toward the overall care target.

  • PEPFAR has adopted the international approach for core services for orphans and other vulnerable children and supported activities corresponding to those services. However, scale-up efforts for the provision of these services are hampered by several challenges, including a lack of social service systems to address the social and mental health support needs of children and a lack of systems with which countries can track and report vital statistics, such as birth registration, to facilitate determination of eligibility for both PEPFAR and non-PEPFAR services. PEPFAR is supporting efforts to develop such systems, and priority to social welfare and education workers in its workforce capacity-building efforts is greatly needed.

  • The Office of the U.S. Global AIDS Coordinator (OGAC) and the U.S. Agency for International Development are collaborating to strengthen the collection and validity of strategic information needed by policy makers and program managers by revising the program-level indicator used to report data; providing clear guidance on how and when a child can be counted as served; standardizing services; and conducting targeted evaluations of service-related issues, including cost and program effectiveness.

  • OGAC efforts to strengthen data could also include its adoption of some of the United Nations Children’s Fund (UNICEF) program and outcome indicators, such as the number of girls enrolled in school and the grade levels they attain, to better position PEPFAR to evaluate the responsiveness and impact of PEPFAR-supported services. Adoption of these indicators could be under taken with attention to continued harmony with one nationally integrated monitoring and evaluation system.



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PEPFAR Implementation: Progress and Promise 7 PEPFAR’s Orphans and Other Vulnerable Children Category Summary of Key Findings As of September 30, 2006, PEPFAR had provided services to more than 2 million orphans and other vulnerable children in the focus countries. There is no specific performance target for the number of orphans and other vulnerable children to be served, instead they are counted toward the overall care target. PEPFAR has adopted the international approach for core services for orphans and other vulnerable children and supported activities corresponding to those services. However, scale-up efforts for the provision of these services are hampered by several challenges, including a lack of social service systems to address the social and mental health support needs of children and a lack of systems with which countries can track and report vital statistics, such as birth registration, to facilitate determination of eligibility for both PEPFAR and non-PEPFAR services. PEPFAR is supporting efforts to develop such systems, and priority to social welfare and education workers in its workforce capacity-building efforts is greatly needed. The Office of the U.S. Global AIDS Coordinator (OGAC) and the U.S. Agency for International Development are collaborating to strengthen the collection and validity of strategic information needed by policy makers and program managers by revising the program-level indicator used to report data; providing clear guidance on how and when a child can be counted as served; standardizing services; and conducting targeted evaluations of service-related issues, including cost and program effectiveness. OGAC efforts to strengthen data could also include its adoption of some of the United Nations Children’s Fund (UNICEF) program and outcome indicators, such as the number of girls enrolled in school and the grade levels they attain, to better position PEPFAR to evaluate the responsiveness and impact of PEPFAR-supported services. Adoption of these indicators could be under taken with attention to continued harmony with one nationally integrated monitoring and evaluation system.

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PEPFAR Implementation: Progress and Promise Recommendation Discussed in This Chapter Recommendation 7-1: The needs of orphans and other children made vulnerable by AIDS cover a wide spectrum that cuts across all of PEPFAR’s categories of prevention, treatment, and care and extends well beyond the health sector. It is essential for an HIV/AIDS response to address these needs adequately—not only to support these children in living healthy and productive lives, but also to protect them from becoming the next wave of the pandemic. The U.S. Global AIDS Initiative should continue to support countries in the development of national plans that address the needs of orphans and other children made vulnerable by AIDS, as well as to support the priorities delineated in these plans. To ensure adequate focus on and accountability for addressing the needs of orphans and other vulnerable children, the U.S. Global AIDS Coordinator should work with Congress to set a distinct and meaningful performance target for this population. This target should be developed in a manner that both builds on the improvements PEPFAR has made in its indicator for children served and enhances its ability to support comprehensive and integrated HIV/AIDS programming.

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PEPFAR Implementation: Progress and Promise 7 PEPFAR’s Orphans and Other Vulnerable Children Category CATEGORY, TARGET, AND RESULTS Category The Leadership Act treats orphans and vulnerable children as a fourth category for purposes of the President’s Emergency Plan for AIDS Relief (PEPFAR) funding and reporting, although the services they receive—prevention, treatment, and care—cut across the other three categories. In PEPFAR’s indicator guidance, an orphan is defined as a child under 18 who has lost either a mother or a father (OGAC, 2005f); in its second annual report, however, PEPFAR defined an orphan as a child under age 15 who has lost a mother, a father, or both (OGAC, 2006a). The Office of the U.S. Global AIDS Coordinator (OGAC) has previously defined vulnerable children as “those affected by HIV though the illness of a parent or principal caretaker” (OGAC, 2005f). New programmatic guidance addresses the conflicts created by varying definitions of those served under this category, which are discussed in detail in the section on issues and opportunities for improvement later in the chapter. PEPFAR’s activities targeting orphans and other vulnerable children fall into two subcategories: services to children and training for providers of those services.

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PEPFAR Implementation: Progress and Promise Target There is no quantified target for the number of orphans and other vulnerable children to be served by a specific deadline, as with the 2010 target for prevention and the 2008 target for treatment (OGAC, 2005c, 2006e. f). However, the Leadership Act mandates that no less than 10 percent of total PEPFAR funding allocated for prevention, treatment, and care be used to provide services to address the needs of orphans and other vulnerable children. Furthermore, the legislation prescribes that of that 10 percent, “at least 50 percent shall be provided through non-profit, nongovernmental organizations including faith-based organizations that implement programs at the community level” (p. 746). However, Country Teams, in collaboration with country governments, do set specific country targets for the number of orphans and other vulnerable children to be served by the program that count towards the 10 million people target for care. Similar to the indicators for the other PEPFAR categories, this indicator counts the number of children provided PEPFAR-supported services (food/nutrition, shelter and care, protection, health care, psychosocial support, and education/vocational training), but does not allow determination of the quality or impact of those services (see Chapter 8 for a discussion of this issue). However, the evolution of PEPFAR’s current indicator for the orphans and other vulnerable children category reflects one of OGAC’s best efforts to strengthen the data provided by care indicators—potentially improving the quality of services, utilizing an approach to meet the individualized needs of children, and at the very least ensuring that recipients are receiving appropriate and standardized services and are being tracked over time. In August 2006, OGAC informed the Country Teams through its News to the Field that the orphans and other vulnerable children indicator had been revised. The revision changes which children can be counted as served by an orphans and other vulnerable children program and how. Many of the PEPFAR targets, other than training, were defined as direct support (downstream) and indirect support (upstream). The corresponding indicators were the number served directly and the number served indirectly, disaggregated by gender. Although targets for the total number of orphans and other vulnerable children served directly for Country Operational Plans for fiscal year 2007 will be set as in previous years, use of the revised reporting indicator will be effective as of the fiscal year 2007 mid and annual reporting periods, with allowance made if the country’s monitoring system is not yet able to provide the new breakdown (OGAC, 2006c,d). The new measure will be divided into two subcategories: orphans and other vulnerable children receiving primary direct support and those receiving supplemental direct support. Direct support is defined as follows: “direct recipients of support are orphans and vulnerable children who are regularly monitored

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PEPFAR Implementation: Progress and Promise in the six core areas (food/nutrition, shelter and care, protection, health care, psychosocial support, and education) and whose individual needs are addressed accordingly. Economic strengthening should be evaluated according to its benefit to the six core areas” (OGAC, 2006i, p. 10). Indirect support for orphans and other vulnerable children support is defined as follows: “indirect recipients of support are orphans and vulnerable children who are NOT individually monitored but who collectively benefit in some way from system strengthening or other interventions. For example, estimated number of orphans and vulnerable children benefiting from a policy change or improved system (i.e., birth registration, inheritance laws, or educational system or the estimated number of orphans and vulnerable children benefiting from the training or support for caregivers)” (OGAC, 2006i, p. 11). Reporting of primary direct support is defined as follows: “count orphans and other vulnerable children who are periodically monitored in all six core areas and who are receiving PEPFAR funded or leveraged support in three or more areas, in the relevant reporting period, that are appropriate for that child’s needs and context” (OGAC, 2006i, p. 11). Reporting of supplemental direct support is defined as follows: “count orphans and other vulnerable children who are periodically monitored in all six core areas and who are receiving PEPFAR funded or leveraged support in one or two areas, in the relevant reporting period, that are appropriate for that child’s needs and context” (OGAC, 2006i, p. 11). Total direct support is the sum of primary and supplemental support (OGAC, 2006i). The indicator guidance also states that the impact of services on children is not to be measured by routinely collected program indicators and references plans to collect national-level outcome and impact indicators periodically through population-based surveys and special studies (OGAC, 2005f). Additionally, the announcement to the Country Teams states that an orphan or otherwise vulnerable child can be counted under only one category (not both direct and indirect) and that program-level monitoring will need to be done by core service area to provide the national-level breakdown between primary and supplemental direct support. OGAC also suggests that tracking this indicator by age group could be helpful for developing appropriate service strategies. The Orphans and Other Vulnerable Children Technical Working Group is available to assist countries that need to develop appropriate and necessary monitoring systems to report on the new indicator. The new definitions and other revisions may cause the numbers of orphans and other vulnerable children served to decrease from their previous annual levels. However, the benefit of measuring impact, measuring longitudinal benefit to orphans and other vulnerable children, and standardizing services to this population will improve the quality of the services provided and yield valuable data to inform future service planning and policy development or reform.

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PEPFAR Implementation: Progress and Promise Results Of the slightly more than 15 million children estimated to be orphaned or otherwise made vulnerable by HIV/AIDS, 7.4 million or 49 percent live in the focus countries (UNAIDS, 2006). Prior to fiscal year 2006, funding for services to orphans and other vulnerable children has been below the 10 percent required by the Leadership Act (see Chapter 3). According to OGAC’s third annual report to Congress, however, the amount for fiscal year 2006 is approximately 12 percent of prevention, treatment, and care resources, but drops to 9 percent if amounts for pediatric AIDS are excluded (OGAC, 2007). By the end of fiscal year 2006, OGAC reported that services had been provided to more than 2 million orphans and other vulnerable children. This is more than triple the children served in fiscal year 2004 (see Table 7-1). As for training in the same time period, OGAC trained six times the number of people to provide services to this population since fiscal year 2004. The number of service outlets (“programs providing care and support for orphans and vulnerable children” [OGAC, 2005a, p. 48]) to which PEPFAR provided technical support for the provision of services to orphans and other vulnerable children was only reported for fiscal year 2004, though OGAC reports it continues to provide technical assistance to an undisclosed number of service outlets as part if its capacity-building efforts. BACKGROUND Estimates of Numbers of Orphans and Other Vulnerable Children In its 2006 Report on the Global AIDS Epidemic, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated the numbers of children orphaned as a result of HIV/AIDS by region and country, using age 18 as the delimiter. Countries were ranked 1–37 (1 being the highest) by the number of such children out of the global estimate of 15.2 million. TABLE 7-1 PEPFAR Orphans and Other Vulnerable Children Results by Fiscal Year, 2004–2006 Category Fiscal Year 2004 Fiscal Year 2005 Fiscal Year 2006 Total orphans and vulnerable children served 630,200 1,222,100 2,000,700 Total people trained as providers 22,600 74,800 143,000 Service outlets 700 Not available Not available SOURCE: OGAC, 2005a, 2006a, 2007.

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PEPFAR Implementation: Progress and Promise TABLE 7-2 Estimates of Living Children Orphaned as a Result of HIV/AIDS in the PEPFAR Focus Countries and Country Population Totals, 2005–2006 Rank Country Number of Orphans due to AIDS (< 18 years)a Percentage of Global Estimate Country Total Population (2006)b Number of Children in Country (0–14 yrs) (2005)b Total OVC Index Score (0–100)b   Global 15,200,000 100.0 N/A N/A N/A 1 South Africa 1,200,000 7.9 47,432,000 15,500,000 69 2 Kenya 1,100,000 7.2 34,256,000 14,700,000 N/A 2 Tanzania 1,100,000 7.2 38,329,000 16,300,000 55 3 Uganda 1,000,000 6.6 28,816,000 14,500,000 65 4 Nigeria 930,000 6.1 131,530,000 58,200,000 46 5 Zambia 710,000 4.7 11,668,000 5,300,000 29 8 Mozambique 510,000 3.4 19,792,000 8,700,000 41 9 Côte d’Ivoire 450,000 3.0 18,154,000 7,600,000 68 11 Rwanda 210,000 1.4 9,038,000 3,900,000 79 15 Botswana 120,000 0.8 1,765,000 660,000 N/A 20 Namibia 85,000 0.6 2,031,000 840,000 73 37 Ethiopia N/A N/A 77,431,100 34,500,000 57 37 Guyana N/A N/A 751,000 N/A N/A 37 Haiti N/A N/A 8,528,000 N/A N/A 37 Vietnam N/A N/A 84,238,000 N/A N/A   Total reported 7,415,000 48.9 513,759,100 180,700,000   NOTE: All data are estimates. UNAIDS indicates that data are still preliminary for Canada, Ethiopia, and the United Kingdom. A child orphaned by AIDS is defined as any living child under the age of 18 who has lost one or both parents as a result of HIV/AIDS. N/A = not available. SOURCE: Compiled from aUNAIDS, 2006, and Kaiser Family Foundation, 2007; bUNICEF, 2006a. The rankings of the focus countries are shown in Table 7-2. As of 2005, South Africa, Kenya, Uganda, and Tanzania had each reported orphan populations of just over 1,000,000. Zambia, Nigeria, Mozambique, Côte d’Ivoire, Rwanda, and Botswana had reported orphan populations in the range of 120,000–930,000, with Botswana at the lowest end of the range and Nigeria at the highest. The estimate for Namibia was 85,000 orphans. The UNAIDS report noted that the data for Ethiopia were preliminary and not included in the table, and no data were reported for Vietnam, Haiti, or Guyana. It is important to note that these estimates do not include other vulnerable children; thus they are underestimates of the numbers of children who should be counted in the category of orphans and other vulnerable children and are in urgent need of services. Though estimates may appear low for some countries, the context of the magnitude of the problem is best

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PEPFAR Implementation: Progress and Promise understood by the proportion of the country’s total population and total population of children the estimates represent. Standards of Care Global Approach to Addressing Needs of Orphans and Other Vulnerable Children International events and efforts by international organizations, governments, and the civil sector led to the development of a normative approach for addressing the needs of children orphaned and otherwise made vulnerable by HIV/AIDS. Box 7-1 presents a summary of these key events. The United Nations Children’s Fund (UNICEF) was instrumental in spearheading the formation of the Global Partners Forum for Children Affected by HIV/AIDS (GPFC) as a focal point for advocacy, dialogue, and prioritizing of action items. The result was a set of recommendations for global action in six key areas: (1) planning for national scale-up response; (2) ensuring that children have adequate legal protection; (3) expanding the role of community organizations in national responses; (4) improving access to education; (5) improving access to health care services for children and caregivers affected by HIV/AIDS, including pediatric treatment and prevention of mother-to-child transmission of HIV; and (6) supporting social welfare interventions. The GPFC was initially convened in Geneva in 2003 by UNAIDS and UNICEF to mobilize action and monitor progress toward fulfilling the global commitments for children affected by HIV/AIDS set forth in the United Nations General Assembly’s 2001 Declaration of Commitment on HIV/AIDS and the Millennium Development Goals (MDGs) (UNICEF, 2006b). The first meeting resulted in endorsement of The Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS (“The Framework”), which has become the normative approach for urgently addressing the needs of orphans and other vulnerable children (UNICEF, 2004). The GPFC’s second convention, held by UNICEF and the World Bank in December 2004, resulted in acceleration of the abolishment of school fees and removal of other barriers to education in a joint effort with the Education for All Fast Tract initiative; the initiation of a system for reporting on care, with indictors to track donor and national government actions and resource commitments to children affected by HIV/AIDS; and the establishment and strengthening of global treatment targets for children with HIV/AIDS. The GPFC’s third convention was held in England in 2006 by the Department for International Development (DFID), UNICEF, and UNAIDS with three major objectives: (1) to measure progress on the previous year’s commitments at the GPFC;

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PEPFAR Implementation: Progress and Promise BOX 7-1 Selected Events Leading to the Development of The Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS 1994: Lusaka Declaration adopted at a workshop in Zambia on support to children and families affected by HIV/AIDS. Issues reflected in the declaration include the need to assess the magnitude of the problem, the role of institutional care, the need for material and financial support for affected families, survival skills and vocational training for orphans and vulnerable children, and their right to basic education. 1998: United Nations held a General Discussion on “Children Living in a World with AIDS.” The discussion stressed the relevance of the rights contained in the Convention on the Rights of the Child to prevention and care efforts, noting that HIV/AIDS was often seen primarily as a medical problem, whereas the holistic, rights-centered approach required to implement the convention was more appropriate to the much broader range of issues that must be addressed. 1998: Regional Children in Distress conference held in Pietermaritzburg, South Africa. Country representatives committed to establishing Orphans and Vulnerable Children Task Teams in their countries. 2000: First East and Southern African regional meeting on orphans and vulnerable children held in Lusaka, Zambia. Countries made commitments and plans to address the issue of the growing numbers of orphans and vulnerable children in their countries. 2001: United Nations General Assembly Special Session (UNGASS) met to review and address the problem of HIV/AIDS in all its aspects, as well as to secure a global commitment to enhancing coordination and intensifying efforts. The resulting Declaration of Commitment on HIV/AIDS includes a specific section and set of policy and strategy actions addressing orphans and other vulnerable children for signatory states. 2002: United Nations Special Session on Children resulted in the “World Fit for Children” declaration. This declaration reaffirmed the goals set by UNGASS in 2001. 2002: Regional workshop on orphans and other vulnerable children held in Yamoussoukro, Côte d’Ivoire, with representatives from 21 Central and West African countries, in the spirit of the Pietermaritzburg and Lusaka meetings. Country representatives committed to setting up task teams in their countries to develop action plans for ensuring achievement of the targets pertaining to orphans and other vulnerable children set forth in the 2001 UNGASS declaration. 2002: Africa Leadership Consultation entitled “Urgent Action for Children on the Brink” aimed at developing consensus on priorities for a scaled-up response to the orphans and vulnerable children crisis. Actions were proposed to mobilize the leadership, partnerships, and resources required to deliver on the UNGASS goals. 2002: Eastern and Southern Africa workshop on orphans and vulnerable children (with representation from 20 countries) held in Windhoek, Namibia, to assess the progress of countries toward meeting the UNGASS goals. 2003: UNAIDS and UNICEF convened the first Global Partners Forum in Geneva. The Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS was endorsed. SOURCE: Adapted from Smart, 2003.

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PEPFAR Implementation: Progress and Promise (2) to identify and remove constraints to expanding the response to children affected by HIV/AIDS; and (3) to enter into a global compact with an agreed-upon manageable and prioritized agenda aimed at expanding efforts to meet the needs and rights of children affected by HIV/AIDS on the basis of emerging evidence (DFID et al., 2006). The United Nations Convention on the Rights of the Child and other human rights instruments guide all actions in support of orphans and other vulnerable children (UNICEF and UNAIDS, 2004). While all eight goals of the United Nations’ Millennium Declaration of 2000 can have an impact on the lives of children, one goal relates directly to HIV/AIDS (UNICEF, 2006c). While the authors of The Framework acknowledged that the response to the orphan crisis was growing, they maintained that the response lacked the “necessary urgency and remain[ed] unfocused and limited in scope.” They also stated that “thousands of community-based programs have been implemented by faith-based and non-governmental organizations as well as communities themselves to ensure the well-being of orphans, but opportunities for significant expansion have not yet been grasped” (UNICEF and UNAIDS, 2004, p. 10). In addition, while more attention is being paid to the inclusion of the needs of these children in poverty reduction and other national development strategies, only two PEPFAR focus countries in sub-Saharan Africa identify orphans and other vulnerable children as “priority actions” in their full poverty reduction strategy papers,1 but neither cites this area specifically in its poverty reduction strategy paper budgets (UNICEF, 2004). In addition, not all focus countries even have national strategies to address the needs of orphans and other vulnerable children. Although OGAC representatives have participated in international efforts to address issues related to implementation of The Framework, OGAC delayed creating official program guidance for services to orphans and other vulnerable children until the late stages of PEPFAR and issued the guidance in final form in July 2006. A specific but limited care package for children living with AIDS was included as an appendix in OGAC’s draft palliative care guidance issued early in 2005 before the issuance of its preventive care guidance for children in 2006. While palliative and preventive care guidance are important, they are not, however, equivalent to official guidance on meeting the needs of orphans and other vulnerable children who are HIV-negative or asymptomatic children living with HIV/AIDS, which was not disseminated until after the publication of OGAC’s second annual 1 According to the World Bank, poverty reduction strategy papers describe a country’s macroeconomic, structural, and social policies and programs to promote growth and reduce poverty, as well as associated external financing needs. The papers are prepared by governments through a participatory process involving civil society and development partners, including the World Bank and the International Monetary Fund (World Bank, 2006).

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PEPFAR Implementation: Progress and Promise report to Congress. OGAC also issued preventive care guidance for children in April 2006 (which is discussed further in this chapter), but this guidance did not comprehensively address the needs of orphans and other vulnerable children as described in The Framework. The sequencing of the various guidance documents issued for orphans and other vulnerable children may have contributed to the fragmented programming that the Committee heard about during its country visits. The Framework The Framework is a consensus document drafted jointly by the U.S. Agency for International Development (USAID), UNAIDS, UNICEF, and more than 90 other child advocacy organizations (UNICEF and UNAIDS, 2004). The five key strategies codified in The Framework evolved from those presented in “Urgent Action for Children on the Brink” in 2002 (UNAIDS et al., 2002): Strengthen the capacity of families to protect and care for orphans and vulnerable children by prolonging the lives of parents and providing economic, psychosocial, and other support. Mobilize and support community-based responses. Ensure access for orphans and vulnerable children to essential services, including education, health care, birth registration, and others. Ensure that governments protect the most vulnerable children through improved policy and legislation and channeling of resources to families and communities. Raise awareness at all levels through advocacy and social mobilization to create a supportive environment for children and families affected by HIV/AIDS (UNICEF and UNAIDS, 2004). These strategies are detailed in Box 7-2. The Country Operational Plans provide examples of PEPFAR-supported activities aimed at meeting the needs of orphans and other vulnerable children. These examples are presented in the next section, organized according to the five key strategies listed above. As families and communities are the first line of response to HIV/AIDS, PEPFAR, through its collaboration with and funding to USAID, has adopted The Framework to address the needs of orphans and other vulnerable children through its community and family-based programs. Many organizations receive PEPFAR funds through grants and contracts from USAID, as it has primary responsibility for oversight and development of programming for orphans and other vulnerable children (OGAC, 2004). PEPFAR has not, however, adopted all of UNICEF’s recommended core or additional indicators for measuring either the services provided or their impact on the lives of orphans and other vulnerable children and communities.

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PEPFAR Implementation: Progress and Promise examples of comprehensive prevention programs for children funded by PEPFAR, it is not clear how the Country Teams can ensure that prevention programs in the school environment will provide the range of prevention and care services needed given the current guidelines and planning and funding restrictions. Preventive Care Secondary preventive care services (including the administration of cotrimoxazole prophylaxis as early as possible for infants and children) have reduced mortality and morbidity not only for those living with HIV, but also for their family members and children (see Chapter 6). As discussed previously, OGAC released guidance for preventive care services for children aged 0–14 born to mothers who are HIV-positive, which was produced through the collaboration of several of the Technical Working Groups—Palliative Care, Food and Nutrition, and Orphans and Vulnerable Children. In recognition of the specific and age-dependent needs of children, the preventive care package for children varies from that for adults in significant ways. OGAC continues to encourage linkages of these services to other programs that support the basic health care and social service needs of children. Antiretroviral therapy and palliative care for children are addressed in additional guidance from OGAC. In addition to the services identified in the adult preventive care guidance as outlined in Chapter 6, the guidance for children specifies direct funding for the following services (OGAC, 2006d): Diagnosis of HIV infection in infants, including purchase of reagents and equipment; establishment of laboratory programs needed to diagnose HIV infection in infants according to national guidelines; training of staff to perform testing; targeted evaluation of practical approaches for scaling up testing in infants; and follow-up and referral at the facility and community levels in accordance with PEPFAR’s network model (see Chapter 6). Childhood immunization, including routine childhood immunizations and pneumococcal and influenza vaccines, referral and follow-up, linkages to routine immunization programs, and technical assistance to develop national policies and training programs for children living with HIV/AIDS. It should be noted that PEPFAR does not directly fund the purchase of routine vaccines for infants and children exposed to HIV, but does support the purchase of vaccines for pilot programs and targeted evaluations of new vaccines for children who are HIV-positive. Prevention of serious infections, including technical assistance for the development of national guidelines and training programs for preventing pneumonia, tuberculosis, malaria, and diarrheal disease in children who

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PEPFAR Implementation: Progress and Promise have not been exposed to HIV or are HIV-positive, with recommended linkages to the President’s Malaria Initiative and the Global Funds to Fight AIDS, Tuberculosis and Malaria. Providing nutritional care, including the provision of daily multiple micronutrient supplements for pregnant and lactating women, children, and especially infants weaned early and children under age 2; vitamin A and zinc supplementation according to national guidelines; and nutritional counseling linked to clinical and home-based care in areas where malnutrition is endemic. Scale-up of PEPFAR’s secondary preventive care services for both children and adults has the potential to help keep parents and families healthier longer, decrease the numbers of children who may become orphaned or otherwise made vulnerable as a result of HIV/AIDS, decrease stigma and discrimination against children and their family members, and improve a household’s ability to positively cope with being affected by HIV/AIDS. Progress in Addressing the Vulnerability of Young Girls OGAC has articulated a commitment to focusing on the special vulnerability of girls to HIV/AIDS and its effects (OGAC, 2005a, 2006a). Many interventions are addressing the factors that make girls vulnerable, including efforts to increase their means of economic/social support, enable them to continue their education, and advocate an end to the practices of early marriage and transgenerational sex as solutions to what families may view as burdens created by orphaned girls (OGAC, 2006a). OGAC has reported that among the orphans and other vulnerable children served by PEPFAR activities, 52 percent have been girls (OGAC, 2006h). OGAC has also reported that PEPFAR is supporting 97 activities aimed at increasing the access of women and girls to income and productive resources (OGAC, 2006h). PEPFAR is also attempting to increase the focus of its programs on gender by working with community partners to reduce violence, including sexual coercion and rape, toward orphans and other vulnerable children, particularly adolescents (OGAC, 2006a). ISSUES AND OPPORTUNITIES FOR IMPROVEMENT Varying Definitions Although the definition of an orphan can differ by country, the main variables are generally age and parental loss (USAID, 2003). International organizations and governments have variably used the under-15 or under-18 age groups to define a child as an orphan if one or both of the parents

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PEPFAR Implementation: Progress and Promise are deceased. USAID supports community definitions of orphans and does not specify a particular age to delimit childhood and adulthood; it also recognizes the international use of the term “child” as defined by the United Nations Convention on the Rights of the Child as any person under the age of 18 (USAID, 2002). The UNAIDS and UNICEF (2003) Report on the Technical Consultation on Indicators Development for Children Orphaned and Made Vulnerable by HIV/AIDS defined an orphan or otherwise vulnerable child as “ a child below the age of 18 who has lost one or both parents or lives in a household with an adult death (age 18–59 years) in the past 12 months or is living outside of family care” (p. 4). In addition, “the concept of vulnerability is complex and may include children who are destitute from causes other than HIV/AIDS” (USAID, 2004, p. 1). The Children on the Brink series was issued in 2002 and 2004 (UNAIDS et al., 2002, 2004). The 2004 publication revised the age used to delimit childhood from under 15 to under 18 in recognition that “orphans and vulnerable children are not necessarily young children and that problems caused by orphaning extend well beyond the age of 15, [with] available data suggesting that adolescents make up the majority of orphans in all countries” (UNAIDS, 2004, p. 4). The definition of an orphan in PEPFAR’s second annual report as a child below age 15 who has lost one or both parents is consistent with that in the 2002 version of Children on the Brink (UNAIDS et al., 2002), but is inconsistent with the 2004 revision. This inconsistency between definitions raises concern about whether PEPFAR service outlets are providing and targeting services to the entire population eligible for those services, and whether the program is overlooking a population of children aged 16–18 who are often the heads of households after the death of a parent or are primary caregivers during the illness of a parent. Another deviation from international definitions is PEPFAR’s definition of vulnerable children as those affected by HIV through the illness of a parent or principal caretaker, which may limit the availability of services for those children who may be in greatest need and at greatest risk for exploitation and increased risk for exposure to HIV. The international community and premier child advocates generally have a more expansive definition of a child’s vulnerability as being affected by any disease, including HIV/AIDS, that afflicts a parent/caregiver; living in a household that has taken in orphans; or living on the streets (UNAIDS, 2004). Vulnerability may also differ by community and intervention (Mahy, 2006). These misaligned definitions may also result in underserving child-headed households and many children who may become vulnerable when their households accept orphans. USAID (2004) acknowledges that the concepts of orphans and other vulnerable children as social constructs have cultural variability, and that depending on their intended versus adopted use, the definitions can often be at odds with each other. For example, the terms may be used for collecting

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PEPFAR Implementation: Progress and Promise and reporting quantitative data, which would differ from their use for the development and implementation of programs and policies. USAID believes that making these distinctions is important and that “firewalls” should be built around the definitions to minimize the potential consequences of deviation from their original purposes. One of the most common misuses of the terms appears to be the use of quantitative definitions for program eligibility. USAID cautions that quantitative definitions must allow for absolute distinctions, whereas the definitions used in policy and program development and implementation must allow for the local variations that contribute to or cause vulnerability. UNICEF has called for programs that address the needs of orphans and other vulnerable children living in a world with HIV/AIDS to serve all children who are orphans and are vulnerable regardless of the cause of their state. The primary reason for this position is that either referring to these children as “AIDS orphans” or limiting their eligibility for services to disease-specific vulnerability could further stigmatize them in their communities and families, which in turn could result in mistreatment and discrimination, alienation, or reluctance to access the very services intended to reduce their vulnerability and exposure to HIV infection and improve the quality of their lives. While PEPFAR remains focused on HIV/AIDS, it has put increasing emphasis on the provision of services to children in the context of other service programs and activities for all children in communities and states that “programs must implement effective measures to prevent gender inequity, avoid further degradation of family structures, reduce stigma, avoid marginalization, and that do not generate jealousy and conflict for beneficiaries. Services need to be designed to reduce stigma, not increase it” (OGAC, 2006i, p. 4). After the publication of its second annual report to Congress and as the program evolved, OGAC disseminated its “Orphans and Other Vulnerable Children Programming Guidance for United States Government In-Country Staff and Implementing Partners.” The guidance includes updated definitions for children orphaned or otherwise made vulnerable as a result of HIV/AIDS (OGAC, 2006i, p. 2): An orphan is a child, 0–17 years old, who has lost one or both parents to HIV/AIDS. A vulnerable child is a child, 0–17 years old, who is more vulnerable because of any or all of the following factors that result from HIV/AIDS: Is HIV-positive Lives without adequate adult support (e.g. in a household with chronically ill parents, a household that has experienced a recent death from a chronic illness, a household headed by a grandparent, and/or a household headed by child)

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PEPFAR Implementation: Progress and Promise Lives outside of family care (e.g. in residential care or on the streets), or Is marginalized, stigmatized, or discriminated against. OGAC’s adoption of definitions that are more closely aligned with the current international consensus (and the realities of the needs of children) eliminates some of the Committee’s concerns about PEPFAR-supported programming, particularly for adolescents and child heads of household who may be in great need of support and services. Establishment of Targets If funding allocations and other budgetary constraints were removed, it would be appropriate for Country Teams, with the help of community-based service providers, to establish quantifiable targets for orphans and other vulnerable children to be served as has been done with PEPFAR’s other categories. Even this target setting should be guided not only by the needs of children orphaned and otherwise made vulnerable by HIV/AIDS, but also by the needs of all children who have been orphaned or made vulnerable by any cause—not equivalently based on the estimated numbers of orphans in each country. Communities and countries would then have the flexibility to tailor their responses to all causes of orphanhood and vulnerability and integrate services for all children, while PEPFAR would be able to implement programs for these children in a community-based, family-centered context that would not increase stigma and discrimination due to HIV/AIDS. Recommendation 7-1: The needs of orphans and other children made vulnerable by AIDS cover a wide spectrum that cuts across all of PEPFAR’s categories of prevention, treatment, and care and extends well beyond the health sector. It is essential for an HIV/AIDS response to address these needs adequately—not only to support these children in living healthy and productive lives, but also to protect them from becoming the next wave of the pandemic. The U.S. Global AIDS Initiative should continue to support countries in the development of national plans that address the needs of orphans and other children made vulnerable by AIDS, as well as to support the priorities delineated in these plans. To ensure adequate focus on and accountability for addressing the needs of orphans and other vulnerable children, the U.S. Global AIDS Coordinator should work with Congress to set a distinct and meaningful performance target for this population. This target should be developed in a manner that both builds on the improvements PEPFAR has made in its indicator for children served and enhances its ability to support comprehensive and integrated HIV/AIDS programming.

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PEPFAR Implementation: Progress and Promise Types and Quality of Services The Committee had difficulty interpreting the reported results for this category and was left with the question of what it really means to have been served or received care as an orphan or otherwise vulnerable child. The Committee has expressed its concern throughout this report about the variability in types and quality of services, but this concern is most pressing with regard to orphans and other vulnerable children. It was difficult for the Committee to discern whether the current measure reflects how many children have received services or the number of times children have received services. Specific concerns relate to which services the children may have received as described in The Framework, whether the services met their changing needs or the intensity of those needs, and whether a child was counted as served each time if he or she received fewer than the core services from multiple providers. Additional concerns include the length of time over which services were provided and the coverage or reach of the program—especially to children in rural areas. The Committee strongly encourages attention to all of these concerns as OGAC collects data based on its revised indicator for orphans and other vulnerable children indicator. It should be noted that PEPFAR is supporting cost-effectiveness studies for orphans and other vulnerable children care as part of its pursuit of best practices for services to this population. Workforce Issues Capacity Providers of health care services to orphans and other vulnerable children are suffering shortages similar to those discussed elsewhere in this report, which will not be repeated here. The multifaceted needs of children, however, require that other sectors, such as education and social welfare, receive more support for increased resources and technical assistance for development. Many countries, for example, have seen an increase in student enrollment with the abolition of fees to create universal access. As mentioned in Chapter 2, however, increasing deaths among teachers and parents or adult caregivers who can pay school fees have affected the quality of education (through interruptions in education; classroom overcrowding, which may be exacerbated by the desire to decrease the vulnerability of orphans and other vulnerable children by increasing school attendance; inadequate teacher training; and closures of schools). The numbers and characteristics of the school-age population have also been affected, as has the ability to attend school at all for children once they have been orphaned or otherwise made vulnerable as a result of HIV/AIDS (Africa Renewal, 1999, 2007; Earth Policy Institute, 2000; Bundy, 2003).

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PEPFAR Implementation: Progress and Promise The U.S. Congressional Research Service (CRS, 2005) cites a study conducted by Hepburn (2001), who found that a teacher who is HIV-positive may lose 6 months of teaching time before dying from the disease. In 2006, Namibia—the country with the smallest reported percentage (0.6 percent) of the global estimate of children orphaned and otherwise made vulnerable because of AIDS—reported that since 2005, it had lost a significant number of teachers to AIDS-related illnesses. According to the Namibian Ministry of Basic Education, Sport, and Culture, roughly 550 teachers annually will die of AIDS-related complications by 2011—fueling teacher absenteeism and leading to a decline in productivity (Kaiser Daily HIV/AIDS Report, 2006). One potential consequence of the deaths of teachers and the interruptions in school enrollment and attendance in many countries is that the countries may not reach their Millennium Development Goals in the area of education. Bundy (2003) has summed it well with the “HIV/AIDS education paradox,” in which “education is seen as the one of the most effective ‘social vaccines’ to prevent HIV/AIDS, but HIV/AIDS destroys education systems.” Child Welfare In August 2006, UNICEF published a companion paper to The Framework entitled Child Protection and Children Affected by AIDS, with the primary purpose of articulating the need to recognize social welfare as a basic part of social services and identify strategies for strengthening this sector to better address vulnerability, abuse, and exploitation. These strategies also include creating legislative frameworks to enforce protective laws; improving the formal care system; supporting and monitoring the well-being of children in informal care; and involving other sectors, such as justice, education, and health, to protect the needs of vulnerable children (UNICEF, 2006c). As most nations have agreed to international conventions on human and children’s rights, governments have a primary role of providing social services to vulnerable people and groups. Of particular importance, skilled staff in social service policy, strategic planning, and child welfare and coordination are critical to implementing any recommendation to provide social services. PEPFAR is strongly encouraged to ensure that social workers, child welfare workers, education leaders, law enforcement personnel, and teachers are accorded equal emphasis in human workforce development initiatives—both in in-service and preservice education efforts, and as part of partnerships between government and nongovernment organizations that may possess the expertise and skilled workers sufficiently and urgently needed to meet the needs of these children.

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PEPFAR Implementation: Progress and Promise Training and Monitoring of Providers While the Committee may have been able to ascertain the names of the implementing partners contracted to offer the training for providers of services to orphans and other vulnerable children from the Country Operational Plans, little information was available about the training facilitators or the curricula. Moreover, monitoring of the performance of these providers may have unique features. For some services, those trained may be facilitators or supervisors of others providing the actual service. For example, those trained do not provide educational services, but ensure that children are enrolled in school, have access to funds for educational fees if necessary, have the supplies needed, and participate actively in school. The training curricula may also vary considerably if caring for children involves awareness campaigns for birth registration; skills needed to navigate systems that provide or certify eligibility for services; and other issues related to child survival, such as immunizations and increased use of cotrimaxozole and other preventive care services. The Committee would also like to see more active monitoring of providers and services that include emotional and nutritional support for children. CONCLUSION The needs of children orphaned or otherwise made vulnerable by HIV/AIDS will continue to grow as the numbers of these children dramatically escalates as the pandemic continues. It is necessary for PEPFAR and other donors to continue to work with national leaders, families, communities, and organizations to focus their program and policy development efforts on ensuring the survival of these children—breaking the cycle of poverty, despair, disease, and death in which they have lived and seen loved ones die. Through these efforts, the U.S. Global AIDS Initiative can make positive and measurable contributions to the improved health, safety, vitality, and happiness of these children in the most appropriate environments for their development—families and communities. REFERENCES Africa Renewal (formerly Africa Recovery). 1999 (December). AIDS saps Africa’s educational system. http://www.un.org/ecosocdev/geninfo/afrec/ (accessed January 3, 2007). Africa Renewal (formerly Africa Recovery). 2007. Education in Africa: Africa Recovery special report. Schools struggling with crises: Financial constraints hamper expansion of primary education in Africa. http://www.un.org/ecosocdev/geninfo/afrec/ (accessed January 3, 2007). Bundy. 2003. Education and HIV/AIDS: Window of hope. Washington, DC: World Bank. CRS (Congressional Research Service). 2005. AIDS orphans and vulnerable children (OVC): Problems, responses, and issues for Congress. Washington, DC: Library of Congress.

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PEPFAR Implementation: Progress and Promise DFID (Department for International Development), UNICEF (United Nations Children’s Fund), and UNAIDS (Joint United Nations Programme on HIV/AIDS). 2006. Technical consultation of global partners forum on children affected by HIV/AIDS. Improving outcomes for children affected by HIV and AIDS: Recapacitating social policy and the state in Africa. London, England: DFID. Donahue, J. 2005. Strengthening households and communities: The key to reducing the economic impacts of HIV/AIDS on children and families. In A generation at risk: The global impact of HIV/AIDS on orphans and vulnerable children. Edited by G. Foster, C. Levine, and J. Williamson. New York: Cambridge University Press. Pp. 37–65. Earth Policy Institute. 2000 (July 18). Africa is dying: It needs help. http://www.earthpolicy.org (accessed January 3, 2007). Foster, G., C. Levine, and J. Williamson. 2005. A generation at risk: The global impact of HIV/AIDS on orphans and vulnerable children. New York: Cambridge University Press. Hepburn, A. 2001. Primary education in eastern and southern Africa: Increasing access for orphans and vulnerable children in AIDS-affected areas. Durham, NC: Duke University. Huni, N. 2006. Technical consultation on children affected by HIV and AIDS: Access to prevention, treatment, and care: Regional perspectives on successes and challenges: Africa (east and southern) (PowerPoint Presentation). London, England: Regional Psychosocial Support Initiative. Kaiser Daily HIV/AIDS Report. 2006 (October 24). Significant number of teachers dying of AIDS-related complications in Namibia. http://www.kaisernetowrk.org (accessed October, 24, 2006). Kaiser Family Foundation. 2007. Children orphaned by AIDS (<18 years old), 2005 global health fact sheet. http://www.globalhealthfacts.org/topic.jsp?i=8 (accessed January 2, 2007). Mahy, M. 2006 (February 7–8). Monitoring and evaluating the response to children affected by HIV and AIDS. Presentation provided at the Technical Consultation on Children Affected by HIV and AIDS. New York: UNICEF. OGAC (Office of the U.S. Global AIDS Coordinator). 2004. The President’s Emergency Plan for AIDS Relief: U.S. five-year global HIV/AIDS strategy. Washington, DC: OGAC. OGAC. 2005a. PEPFAR first annual report to Congress. Washington, DC: OGAC. OGAC. 2005b. Final draft HIV/AIDS palliative care guidance #1: An overview of comprehensive HIV/AIDS care services in the President’s Emergency Plan for AIDS Relief. Washington, DC: OGAC. OGAC. 2005c. FY2005 funded targeted evaluation studies: Status update. Washington, DC: OGAC. OGAC. 2005d. FY2005 Country Operational Plans. Washington, DC: OGAC. OGAC. 2005e. PEPFAR ABC guidance. Washington, DC: OGAC. OGAC. 2005f. The President’s Emergency Plan for AIDS Relief: Indicators, reporting requirements, and guidelines for focus countries (revised for FY2006 reporting). Washington, DC: OGAC. OGAC. 2006a. PEPFAR second annual report to Congress. Washington, DC: OGAC. OGAC. 2006b (June 12–15). Building on successes: Ensuring long-term solutions. Annotated version of rapporteur presentations at the President’s Emergency Plan for AIDS Relief 2006 HIV/AIDS Implementers’ Meeting, Durban, South Africa. OGAC. 2006c. Adult preventive care guidance. Washington, DC: OGAC. OGAC. 2006d. Child preventive care guidance. Washington, DC: OGAC. OGAC. 2006e. FY2006 funded targeted evaluation studies: Status update. Washington, DC: OGAC. OGAC. 2006f. Centrally-funded targeted evaluation studies: Status update. Washington, DC: OGAC.

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PEPFAR Implementation: Progress and Promise OGAC. 2006g. FY2006 Country Operational Plans. Washington, DC: OGAC. OGAC. 2006h. PEPFAR report on gender-based violence and HIV/AIDS. Washington, DC: OGAC. OGAC. 2006i. PEPFAR’s orphans and vulnerable children programming guidance for United States government in-country staff and implementing partners. Washington, DC: OGAC. OGAC. 2007. PEPFAR third annual report to Congress. Washington, DC: OGAC. Phiri, S. N., and D. Tolfree. 2005. Family- and community-based care for children affected by HIV/AIDS: Strengthening the front line response. In A generation at risk: The global impact of HIV/AIDS on orphans and vulnerable children. Edited by G. Foster, C. Levine, and J. Williamson. New York: Cambridge University Press. Pp. 11–36. Population Council. 2004. Challenges faced by households in caring for orphans and vulnerable children: Horizons research update. Washington, DC: Population Council. Save the Children. 2004. Beyond the targets: Ensuring children benefit from expanded access to HIV/AIDS treatment. London, England: Save the Children. Sharp, N. 2005. Birth registration: Technical consultation of global partners forum on children affected by HIV and AIDS. Presentation at the PEPFAR Second Annual Field Meeting, Addis Ababa, Ethiopia. Smart, R. 2003. Policies for orphans and vulnerable children: A framework for moving ahead. Washington, DC: The Policy Project. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2004. “Three ones” key principles. Conference paper 1, Washington consultation of April 4, 2004. Geneva, Switzerland: UNAIDS. http://www.unaids.org/NetTools/Misc/DocInfo.aspx?LANG=en&href=http://gva-doc-owl/WEBcontent/Documents/pub/UNA-docs/Three-Ones_KeyPrinciples_en.pdf (accessed September 20, 2006). UNAIDS. 2006. 2006 report on the global AIDS epidemic. Geneva, Switzerland: UNAIDS. UNAIDS and UNICEF (United Nations Children’s Fund). 2003. Report on the technical consultation on indicators development for children orphaned and made vulnerable by HIV/AIDS. Geneva, Switzerland and New York: UNAIDS and UNICEF. UNAIDS, UNICEF, and USAID (U.S. Agency for International Development). 2002. Children on the brink 2002: A joint report on orphan estimates and program strategies. Geneva, Switzerland: UNAIDS. UNAIDS, UNICEF, and USAID. 2004. Children on the brink 2004: A joint report on orphan estimates and program strategies. Geneva, Switzerland: UNAIDS. UNICEF (United Nations Children’s Fund). 2004. Background and policy discussion oral report on the global challenge of orphans and vulnerable children. New York: UNICEF. UNICEF. 2006a. Africa’s orphaned and vulnerable generations: Children affected by AIDS. New York: UNICEF. UNICEF. 2006b. Report on 3rd global partners forum for children affected by HIV/AIDS. New York: UNICEF. UNICEF. 2006c. Child protection and children affected by AIDS: A companion paper to the framework for the protection, care and support of orphans and vulnerable children living in a world with HIV and AIDS. New York: UNICEF. UNICEF and UNAIDS. 2004. The framework for the protection, care and support of orphans and vulnerable children living in a world with HIV and AIDS. Geneva, Switzerland: UNAIDS. UNICEF, UNAIDS, and Futures Group. 2004. National response to orphans and vulnerable children in sub-Saharan Africa: The orphans and vulnerable children programme effort index. New York: UNICEF. USAID (United States Agency for International Development). 2002. Expanded response to core indicators. Washington, DC: USAID.

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