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Caring from within: Key policy recommendations on Home Based Care in Zimbabwe
Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) and Health and Development Networks (HDN)
August 06, 2008

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Executive Summary

In Zimbabwe, as in many parts of sub-Saharan Africa, home-based care (HBC) plays a vital role in the response to HIV as overwhelmed public health and welfare systems fail to cope with the demands of the epidemic. HBC organizations have evolved and grown relatively organically throughout Zimbabwe in response to the epidemic, supporting and directing the activities of caregivers as the epidemic
has dictated.

To understand more about the development of HBC in Zimbabwe and its future potential, Irish Aid engaged Health & Development Networks (HDN) and the Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) to assess and document lessons from HBC interventions. Since 2005, Irish Aid has supported HBC initiatives in Zimbabwe, and is currently funding 15 HBC programmes throughout the country. The current project was designed to contribute to better understanding and evidence-based decision-making in the implementation of HBC interventions in Zimbabwe and beyond.

The evidence gathered by the project was compiled through a qualitative analysis of eight purposefully selected Irish Aid-funded HBC projects. The qualitative data for each project was collected through five main approaches:

• In-depth interviews: These comprised one-to-one interviews with HBC project/programme implementers; focus-group discussions with caregivers, beneficiaries and community leaders; and additional interviews with key informants.
• A comprehensive literature review.
• An online eForum discussion, conducted to solicit broader views about HBC.
• Key Correspondent articles: These were based on project site visits and interviews conducted with people living with HIV (PLHIV), caregivers and community leaders, capturing and documenting first-hand accounts of local and personal realities surrounding HBC and related themes.
• A home-based care learning event, which brought together over 100 participants in Harare, to gather information.

The goal of this publication is to guide HBC implementers, policy-makers, regional and international organizations, and donors in designing and prioritizing HBC programmes, creating policies and targeting funding to make a real difference to people's lives at the local level. As well as summarizing the main findings of the current project, it presents four sets of specific recommendations.

Key recommendations 1: Implementing HBC policies in Zimbabwe

Various policy gaps currently hamper the efficient and effective delivery of HBC services. The following key recommendations should be considered in addressing these gaps and during the future formulation of HBC policy:

• While antiretroviral (ARV) treatment guidelines are already in place, they should be directly linked to HBC. The link needs to be outlined in national treatment guidelines, indicating clearly the role for community-based volunteers in nutrition counselling and treatment adherence support.
• Practical, clear guidelines should be developed to promote the recruitment and involvement of men in care work, including HBC services.
• An HBC volunteer policy should be developed, with close participation of volunteers and other key stakeholders.
• National policy guidelines should be developed to promote effective integration strategies for HBC services.
• Herbal remedies are widely regarded as 'alternative therapies' within HBC programmes, and a need exists for guidelines providing clear direction on how they should be used alongside ARVs.
• Building the capacity of volunteer caregivers to transfer skills to family members and other primary carers should be included in future HBC policy development and elaboration.
• A professional code of conduct for caregivers must be developed that guides their actions.
• Effective partnerships between affected communities, nongovernmental organizations (NGOs), governments and international organizations/agencies are essential to HBC, and this should be reflected in future HBC-related policies.
• Donors participating in the Expanded Support Programme (ESP) are encouraged to play a lead role in leveraging the participation and support of other donors and aligning programmatic interventions that can help to strengthen the reach and impact of HBC services.

Key recommendations 2: The role of caregivers in HBC

There are a number of key recommendations that should be considered in helping to empower caregivers to execute their role in the community effectively:

• Caregivers are at the heart of HBC interventions - appropriate policies and guidelines should be put in place to provide incentives and psychosocial support to caregivers.
• HBC implementers must strive to inform the community about the selection criteria for carers. Standard terms and conditions of service for HBC volunteers should be developed.
• Community ownership and involvement helps to strengthen HBC activities, but implementers and policy-makers must ensure that many people in the community are involved as caregivers (not just - as now - women, particularly elderly women).
• The local community, including relevant leaders, should be involved in the conceptualization, inception and execution of HBC programmes. Services should respond to the felt needs of the community and use such information for planning and programming.
• Social openness about HIV should be encouraged in the community as a way to combat HIV-related stigma and discrimination. A code of ethical conduct should be put in place for caregivers, and sufficient forms of redress for professional violations must be made available.
• Caregivers should be constantly encouraged to protect the privacy of PLHIV under their care.
• HBC programmes must ensure that universal precautions are promoted and adhered to among caregivers, including ensuring the availability of essential supplies such as soap and gloves.
• Volunteer retention can be achieved through the provision of basic tools such as uniforms, shoes, soap, bicycles and full, standard HBC kits. Incentives should include items that compensate for an individual's time spent on the HBC programme, including recognition, participation in income generating projects, food packs and sometimes money.
• Training packages must be developed for caregivers so that they increase their knowledge about how to deliver AIDS care in the most effective ways. Training in treatment literacy should be a compulsory component of HBC training.
• Regular refresher courses incorporating new developments in HIV- and TB-related issues need to be provided to caregivers.

Key recommendations 3: Challenges faced by HBC services

• The international community needs to urgently consider providing support to Zimbabwe, purely on humanitarian grounds.
• National HBC policy should address the issue of resource mobilization to ensure that the effectiveness of potential and existing HBC programmes/organizations is not compromised by a lack of resources.
• The Government of Zimbabwe should support HBC programmes by creating a conducive environment that enhances the accessibility of financial resources and materials, including ARVs.
• National AIDS Council (NAC) coordination of HBC services needs to be strengthened. It is recommended that the NAC and the Zimbabwe AIDS Network (ZAN) should organize platforms for information exchange, experience sharing and peer review among HBC organizations.
• The administrative budgets for HBC organizations should be constantly reviewed upwards in line with the current economic (and inflationary) environment.
• The budgets for relevant projects, including HBC programmes, income-generating and food-security projects (e.g. nutrition gardens, chicken projects) should include sufficient provision to ensure a reliable supply of potable water, through sources such as boreholes.
• Those working in and with HBC programmes must be provided with training to improve the documentation of their work, especially in relation to potentially replicable best practices.
• Youth programmes for both in- and out-of-school children must be incorporated into HBC activities.
• HBC approaches should be expanded to enable children to be loved, provided for and cared for in families and communities.
• HBC programmes must make an investment in understanding the needs of specific groups - such as old women, youth and children - so that they can develop appropriate response strategies.
• Support for community- and home-based care initiatives should be improved by ensuring consistent funding for sustained periods, as well as the provision of technical support to funding recipients. Funding agencies should also prioritize the strengthening of the organizational capacity of HBC organizations and projects.
• Promoting access to water and improving general sanitation should be an underlying theme of all HBC interventions.

Key recommendations 4: An integrated HBC approach

An integrated approach will require better management, planning, resource allocation and monitoring by HBC programmes. Key recommendations that should be considered when implementing an integrated approach include:

• Funding agencies should provide support for infrastructure development and capacity building within health systems. Greater attention must be paid to the roles and needs of health-care workers.
• There is an acute need for ongoing support to develop project-proposal-writing and financial-management skills within HBC programmes.
• Those working in and with HBC organizations require ongoing training and support so that they fully understand the issues that they have to deal with at community level.
• HBC programmes need to establish, expand and manage strategic partnerships with other sectors in the community in order to enhance the integration of services.
• Information, education and communication (IEC) materials and messages should be standardized through the NAC IEC committee.
• Gender-awareness training and a focus on children must be central to all integrated approaches.
• The meaningful involvement of PLHIV in the design of programmes and the identification of priorities is essential to the success of an integrated approach.
• The local community must also be involved in designing, implementing and evaluating integrated programmes.
• There is an urgent need for policy and technical guidelines on how to integrate HBC services with other health-care services.
• Funding agencies must prioritize the funding of HBC activities that use a comprehensive and integrated approach.

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