Local Government

Resilience and Leadership Beyond 2004

To strengthen gendered planning for World AIDS Day 2004, under a ?caring together for women and children? flag, eThekwini Municipality and the Gender AIDS Forum (GAF) partnered in a series of October workshops. Targeting inter alia VCT counselors, occupational health and safety managers, and employee assistance practitioners from government and NGO settings, objectives for the workshops included:

? deepening understanding of the need to focus on women and girls in the HIV/AIDS context,
? popularizing findings of the report of the United Nations? Secretary General?s (SG) task team on women, girls and HIV/AIDS,
? exploring how the latter report could be used for World AIDS Day activities, and
? reflecting on the extent to which HIV/AIDS work is currently gendered.

The SG task force was established in 2003 to investigate HIV/AIDS issues particular to women and girls in southern Africa. On-the-ground consultations in the nine countries in the sub-region with the highest HIV prevalence rates , resulted in valuable empirical data on the scale and character of the epidemic, as well as six areas in which intervention is most needed.
Vicci Tallis from GAF, also a member of the SG task force, reported on these six focal areas in the report, which also outlines changes required of governments in enacting legislation and developing policy and programmes.

Six focal areas identified by the SG?s Task Team on Women, Girls and HIV/AIDS

? Prevention
The report argues that a critical factor driving the epidemic is the prevalence of sexual relationships between young girls and adult males (5 to 10 years their senior). Power differentials in these partnerships place girls at higher risk of infection through abuse, exploitation and violence. Prevention efforts should acknowledge limited choice of these girls to make informed, voluntary decisions concerning abstinence, faithfulness and condom use.
The report argues for increased government participation in efforts that deepen public awareness of the inappropriate, abusive and illegal nature of sexual relationships between girls and older man. Government should also consider that efforts that give women voices to the solution and deal directly with taboo subjects require ?safe spaces? for dialogue.

? Education
Although school enrolment rates for girls in southern Africa are notably higher than those for boys, a challenge is to keep girls in school. Anecdotal evidence suggests that girls leave school when they are orphaned, or to care for the sick, or because of the economic impact of HIV/AIDS on their families.
Subsidising or abolishing school fees and keeping the costs of textbooks and school uniforms to a minimum are alternatives that require creative thinking by government. In Namibia and Swaziland, economic support is provided to poverty-stricken schools, as are cash grants to poor families and income-generation opportunities for girls.
Flexible learning options like double-shift systems, multi-grade teaching, distance education and minimum learning packages are other options. Education through the radio and through community members at public venues have been successful in Zambia and Malawi.

? Violence
Violence increases the risk of HIV infection. Short-term treatment (such as post-exposure prophylaxis) can avert infection, but research on long-term, indirect effects indicates that sexual violence increases the probability that a girl or woman will engage in high risk sexual behaviour later in life.
Grassroots initiatives that offer shelter and counseling and encourage access to judicial and health-care systems are imperative. The South African government, in partnership with various NGO?s, has established over 90 ?one stop? facilities for survivors of domestic violence and sexual assault. These sites offer access to police, social workers, counselors and health care. A growing number of men are joining the struggle against sexual violence. One such group includes the South African NGO Men For Change.

? Property and inheritance
The challenges of civil and customary law include denial of womens? rights to own or inherit land or property. Destitution after the death of a husband, partner or parent can place a women at a higher risk of exploitation, violence and HIV infection.
Remedies available to governments inter alia include measures to restore dispossessed property, training of paralegals to provide advice and assistance, overhauling cumbersome land administrative systems, incorporating material on property and inheritance rights and succession planning into a variety of settings.

? Women and girls as care-givers
Women are generally the voluntary care-givers to orphans, the sick and the dying in society. Few rewards are associated with these roles which place them at higher risk of infection. The report motivates for a volunteer charter to clarify the working hours, remuneration, psycho-social support and other protections required to perform this labour. Supplies to cope effectively, like gloves, bleach and food should be provided. Access to sustainable income-generating projects is a further proposition.

? Barriers to medical care and treatment
The report identifies fear of stigma, violence and discrimination on disclosure of HIV status as serious impediments to women?s access to care and treatment. Efforts that move beyond women to their partners and the community contexts within which women are located are mooted. Increased involvement of male partners in MTCT plus initiatives is one proposed avenue for further exploration.

In addressing these issues with participants, Vicci emphasized the importance of partnerships, particularly intimate partnerships. Intimate relationships have the potential to be fundamental building blocks of challenge to existing networks that perpetuate stigma and discrimination. She called into question differentiations between the public and private spheres of life that condone empowerment in work settings, but reinforce disempowerment in the home environment.

She highlighted five conceptual frameworks that govern the southern African HIV prevention programmes she encountered as a member of the SG task team. The majority were either gender stereotypical, gender neutral or gender sensitive in terms of their focus or messaging. Fewer programmes were empowering or transformative. In moving from situations where others have ?power over?, to situations where change agents have ?power to?, she challenged participants to adopt targeted messaging strategies that accommodate the varied norms and values that govern sexual behaviour.

Dr Ayo Olowalagba, Deputy Head: eThekwini Health, and Jabulile Madondo, Manager of the eThekwini AIDS Programme, emphasised local government?s commitment to strategies that facilitate communities? access to information, training and resources.

Training opportunities through the eThekwini AIDS Programme: 2005

The eThekwini AIDS Programme is offering a variety of training courses in 2005. By March 2005, nine facilitators, representing various sectors, will serve as an interface between the community and the AIDS Programme. The facilitators will be responsible for establishing forums and facilitating access to kits, supplies and training.

One of the priority areas for 2005 will be assisting lay counselors and CBO?s to set up and obtain accreditation for voluntary counseling and testing (VCT) sites. The AIDS Programme has a checklist of activities and resources that can be used as a guide. Given that legislation limits testing activities of lay counselors to screening, CBO?s and lay counselors are encouraged to link with retired nurses and sessional doctors in the delivery of VCT services.

In an exciting development, the local authority will, through funding from national government, roll out a fifty-nine day home-based care training programme. The training package, accredited through the Skills Development Act, is comprehensive and includes topics ranging from voluntary counseling and testing, prevention-of-mother-to-child-transmission, to antiretroviral therapy. Pre-testing, weekly tests, practicals and a final exam constitute evaluation mechanisms. Training encompasses opportunities for practical application of skills in peer education, counseling and home-based care. Accredited home based carers (i.e. those completing the course) will be eligible for employment by government. Communty or group representatives will be able to lodge applications for the free blocked or staggered training of their members with the community-based facilitator, once appointed. For further details please contact either
Sandra Zuma or Krishnee Nair on 3003104.

RESEARCH ON THE AGENDA

The eThekwini Health Deaprtment is taking steps to ensure that it?s research partners participate in the development of a health policy framework for the eThekwini health district. A step in this direction in 2004 was a workshop for eThekwini health managers, representatives from the eThekwini research committee, ?Health, Safety and Security? councilors, representatives from eThekwini Environmental Health, the manager of eThekwini clinic services and representattives from organisations who have submitted proposals for research to the eThekwini Research Committee to date (i.e. over the past three years of its existance), including HIVAN, CAPRISA, the Health Systems Trust and the Medical Research Council.

The following topics were deliberated in focus groups:

? reasons for developing a health policy framework,
? broad strategies or principles for consideration,
? communication (including dissemination and monitoring) and
? mechanisms for health research management.

The following are some inputs made on each topic.

Why do we need a health policy framework?

Participants acknowledged that a framework would facilitate co-ordination and participation, and protect research participants. A framework will allow eThekwini to take a leadership role in defining research needs versus reacting to research requests. It could further promote access to funding and specify mechanisms for application for funding. In providing guidelines for relevant research it could include criteria for evaluation of proposals.
A framework will further structure relationships with external research institutions (e.g. if priorities are set once a year, research institutions can focus on these priorities in, for example, guiding students or in their own research). A framework will provide mechanisms to maintain ethical standards, to monitor the quality of research, to implement recommendations emanating from research and to set objective standards.

Some strategies or principles to consider

It was agreed that broad limits for participation should be considered. These could be
defined more specifically at operational levels. A user-friendly, comprehensive policy that worked within national guidelines is important as is evaluation through an independent forum (e.g. district health forum). It was further mooted that the policy stipulate criteria for acceptance of proposals that are multi-disciplinary, impact positively on service delivery and that build on prior research. Use of accredited institutions to assist with ethics approval was further suggested.

Participation and communication mechanisms

It was advocated to involve appropriate representatives in the communication of the policy (perhaps accomodate ad hoc participation), with an emphasis on incorporating representation from operational levels. Identification of existing fora for participation and dissemination of information was agreed as was the establishment of new fora, if relevant. Open research days and a research-focused newsletter were also seen to be effective communication vehicles. It was further suggested to create pathways of referral for research outcomes if results cannot be implemented at the level of the eThekwini health district

Management of health research

Participants suggested that eThekwini extend the portfolio of the research committee and equip line management staff with research skills. Facilitation of funding for implementation of research findings and for capacity building of staff was seen to be critical. Involvement of the Provincial Department of Health was another point highlighted.

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