Home-based caregivers in Africa: alliance building, advocacy and policy environments.

Ransom, Pamela E. ; Asaki, Becca

In Africa, many individuals still struggle daily with the challenges of HIV/AIDS. Although medical advances continue, over 23.5 million people, or just over two thirds of the world's total cases, were documented in the region in 2011 (Kaiser Foundation, 2012 p.1). Home-based care represents an important and often only option, for many of the neediest living with HIV/AIDS and other disabilities across the continent. Shortages of formal health workers are sometimes compensated by this form of community-based labor and it has been noted that up to 90% of care is provided by these care-givers. Indeed, "Health care, most specifically TB and HIV care, would simply be unimaginable without the services of an army of lay health workers" (Schneider, Lehman, 2010 p. 61).

Care is provided in the home through a spectrum of arrangements. A complex relationship now exists between government run health services and individuals providing home-based supportive health and social services in a variety of formats. Community home-based care (CHBC), was defined in the Gabarone Declaration that emerged from a conference of representatives from 10 countries in the region as "the care given to an individual in his/her own environment (home) by his/her family and supported by skilled welfare officers and communities to meet not only the physical and health needs, but also the spiritual, material, and psychosocial needs" (ProCAARE, 2001; Family Health International, 2004, pg. 7). Community health workers (CHW's) are employed in the formal health system performing generalist health service and community functions, although these programs have been noted to receive relatively low "moral or financial support" (Schneider, Lehman, 2010 p.62). Ama and Seloilwe (2010) identified three variations of home-based care models including the "facility-based" model involving medical professionals, the purely volunteer community based model and an integrated model that involves partnerships between a range of actors.

Home-based caregiving largely relies on networks of women who perform a range of health and psycho-social tasks. In many cases, women originally entered into these roles because of unmet needs of friends and family suffering from HIV/AIDS. Gender role segregation and stereotypes continue to influence the dominance of women as caregivers and the relative lack of recognition of the role. Caregivers often provide anti-retroviral treatment in patients' homes, thereby removing important barriers to access (Past Due, 2012). Services also range from various forms of counseling, nutritional guidance, HIV prevention, disclosure as well as other forms of emotional support (Boryc, et al. 2010).

Support for caregivers occurs through a variety of means. NGO's and faith-based organizations began to be engaged in home-based care programs in the 1990's. In some cases home-based care workers were provided training in palliative care. Mohammed and Gikonyo (2005) conducted a study of grassroots community home-based care organizations in Africa in countries with the highest rates of HIV. Respondents pointed out that home-based care workers in addition to providing care to impacted families, also provide holistic care, and expanded community information on HIV/AIDS. The community home-based care system was also found to have inadequate resources to meet required needs, with another study identifying relatively weak links not only between community home-based care organizations (CHBC) and the public health sector, but also between CHBC organizations and more well established NGOs and agencies.

In spite of this, the impact of home-based care is clear. Babigumira, Sethi, Smyth and Singer (2009) analyzed comparative outcomes of home-based versus facility based care in antiretroviral therapy (ART) programs in Uganda, finding that both life expectancy and quality of life lived (as measured by QALY) were lower for facility versus home-based care. Bowie, Gondwe and Bowie (2010) examined over one thousand patients in urban Malawi receiving home-based care to assess mortality trends and treatment response. While levels of mortality were high, with just over half of the patients dying from HIV/AIDS, over the course of the research mortality dropped from 28 to 20% with the numbers of new patients seeking care declining 8%. Despite availability of ART, study findings affirmed the continued need for home-based care, with four or five new patients seeking care from a population of 100,000. Ramashwar's (2010) research in Uganda documents similar mortality rates for HIV patients receiving home and clinic based care, but found that home-based care results in reduced costs for patients, speculated to be a result of lower expenses in a variety of areas as a result of improved support.

THE HOME-BASED CARE ALLIANCE

Activism and organization among grassroots women involved in home-based caregiving is growing because of the need for communication, bonding and self-empowerment for those engaged in the caregiving role. In 2005, Groot's International in partnership with national affiliates, Groots Kenya and the Uganda Community Based Association for Community Welfare (UCOBAC) launched the Home-based Care Alliance (the Alliance) that has emerged in recent years as the prime organizational framework for caregivers across Africa. Groots International is a global network formed to support grassroots women's organizations working across national and regional boundaries. It is part of the Huairou Commission, launched by the former head of UN Habitat, which serves as a secretariat to link and support similar grassroots women's networks around the world.

The Alliance provides a framework for home-based caregivers to work together on tasks including advocacy, mobilization, networking and organizing. This grassroots driven entity has been growing steadily with almost 30,000 caregivers as of 2012, who have become part of the Alliance since its inception (Grassroots Women Caring, Groots International. 2009). The Alliance has emerged as a federation of locally based groups who elect leaders who coordinate with other home-based caregiver community leaders in hierarchies of district, regional and national leadership teams or boards. Most groups build from the bottom up, often starting with a cluster of about 20. They often engage in a community mapping process to identify caregivers and expand membership over time with up to 1,000 in some communities and many thousands in some countries (See Table 1.1). Caregivers often meet weekly or monthly in groups of various sizes for information sharing and exchange ("Alliance Expanded," 2011).

Objectives of the Alliance are to be a platform for coordination, peer learning, and advocacy by transferring funding and decision-making directly to home-based caregivers. Another goal is to establish home-based caregivers as evaluators and monitors of AIDS, development, health funding and programming and to reduce the "financial drain of caregiving through collective livelihoods, income-generation and savings and credit schemes" (About the HBCA, p. 4.).

Coordination of Alliance work in Africa is primarily grassroots driven although it is also supported not only through Groots and the Huairou Commission at the international level, but also through a grassroots NGO (See Table 1.1) These organizations ensure appropriate operational capacity at the national level in countries throughout east, south and West Africa in areas such as providing meeting space, grant-writing and accessing funding and facilitating communication.

The idea of an alliance originally came from a 2003 meeting in Nigeria between representatives of the Global Fund to End HIV and Tuberculosis and the Huairou Commission and Groots International. Global Fund meeting participants raised the fact that they were having difficulties channeling funds directly to caregivers, who were on the frontlines of providing care for those dying and ill from HIV/AIDS in Africa. Since grassroots women's organizing and self-empowerment was the specialization of the Huairou Commission and Groots International, the home-based care Alliance was formally born in 2005 in a grant from the Tides Foundation (Asaki, 2012).

This study was initiated by the international Home-based Care Alliance coordinators, Groot's International and the Huairou Commission, in order to better understand the views of Alliance members and coordinating groups. The aim was to explore the interface between these networks and the strategies of external government actors and ongoing efforts for health system change and reform, particularly as it relates to the home-based caregiving role in Africa.

METHOD

A survey was administered by email and telephone follow up from August 2011 to early 2012 to the Home-based Care Alliance national coordinating organizations in each of the 14 African countries where the Alliance is represented. Each of responses reflect input directly from caregivers in each country, with at least one focus group organized by the national facilitating organizations in each of the countries to gain feedback about survey questions between August and December of 2011. The focus groups ranged in size and included both Alliance elected leaders (who are caregivers themselves) and regular home-based caregiver Alliance members. Results were compiled by Alliance national coordinating organizations, with ten final survey responses returned including four from southern Africa (Zambia, South Africa, Zimbabwe and Malawi), three from East Africa (Uganda, Rwanda and Kenya) and three from West Africa (Nigeria, Cameroon and Benin).

The questionnaire was organized around three broad areas (a) existing programs and new policies in impacting caregiving, (b) the broader policy environment impacting caregiving and (c) caregiver advocacy. The issue of trends in the national policy environment impacting caregivers explored developments related to health system strengthening, a subject reflecting agenda's recently established by the World Health Organization (WHO, Everybody's Business, 2007). Finally the theme of caregivers and advocacy used open-ended questions to determine what caregivers are advocating for.

In addition to the surveys and focus groups, in March, representatives from the home-based care Alliance leadership in seven countries including Ghana, Kenya, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe participated in a conference call arranged through the international Huairou Commission to reflect on emerging trends related to caregiving as a follow up to the survey. The conference call resulted in a series of conclusions and recommendations reported below.

The study methodology has some limitations including the fact that the study was designed for program administration rather than for academic purposes resulting in questions that were often open-ended, allowing the respondent rather broad leeway in structuring responses to give greater room for characterization of the issues of concern expressed by Alliance members at the local level. In addition, responses were provided in a range of languages and with varying level of detail, so some challenges occurred in interpretation of responses.

RESULTS

Home-based Caregiving Programs and New Policies

The survey first asked respondents about programs and new policies coming into their community related to home-based caregiving. The summary of survey responses are grouped by each of the three regions of Africa (west, south and east) represented in the sample. Responses illustrated in Table 1.1 shows highlights of responses from West Africa on availability of home-based care programs including finance and other types of support programs for caregivers and comments about awareness of new policies regarding home-based caregivers coming into communities. Data on the numbers of country Alliance members, numbers of people cared for ("friends") and the name of the national NGO coordinating organization is also shown.

The table above shows that in Cameroon, where Alliance members in the region are highest, new policies include a home-based care pilot by the Ministry of Health that offers "a complementary approach to medical services by providing an integrated package of interventions." This includes training of service providers and supervisors, organizing home visits, monitoring and evaluation. While caregiver finance is only sporadically offered through small programs or civil society, the country also has an interesting "referral system coming into place to link home-based care providers with conventional medical practitioners." Caregivers were also benefitting from educational strategies and "community level sensitization" as well as from free vaccinations for clients under government campaigns, free screenings and access to ARVs.

Nigeria, while not reporting any specific new policies for home-based care, was the only one of the reporting countries in the region where financing, programs for social protection, material support and transport stipends were all being provided for caregivers. Caregivers there gain not only "as a direct beneficiary" but also as a result of "partners who help to reach clients in the area." Monthly stipends through some organizations have "increased women's leadership through the collective voice of women caregivers" because caregivers use their monthly contribution for things like "micro-finance towards their economic empowerment." Caregivers were also aware of a program through the Ministry of Health and Institute of Virology that provides direct access to caregivers at 12 hospital sites.

In Benin, the work of home-based caregivers was "not yet organized enough to be recognized by the government" and while volunteers work individually with patients with AIDS, they have no form of recognition. Some regional training for "mediators" was mentioned and since 2006, the Alliance facilitating organization in the country has worked with volunteers to provide assistance to people with AIDS and is now trying to create a more organized Alliance presence among caregivers.

In Southern Africa there is a somewhat different picture as shown in Table 1.2 In Zambia, where the number of Alliance caregiver members in the region is highest there were also no reports of new policies or financing programs for caregiving. Other "programs supporting caregivers are those being funded by cooperating partners" in which caregivers are being trained and given tools for work. While caregivers "take care of clients, facilitate that the clients meet their review schedules, train secondary caregivers and counsel clients" it was stated however that "benefits are mainly emotional" because they "feel the satisfaction that comes being a respected and useful member of the community and from seeing someone once very sick enjoy good health."

With respect to new policies Zimbabwe's survey states simply that, "for more than ten years now, the ... Home Based Care Policy was put up by the government, together with the HIV Policy and the Discharge Guidelines." The table above shows availability of a program to finance home based caregivers. Seke Rural Home-based Care" [the Alliance support NGO], supports caregivers with "some income activities e.g a peanut butter making project and rearing chickens for sale" and "the Global Fund ... also provides $15 per month. Each round [of two funding rounds] pays only 60 caregivers each, totaling 120 caregivers." Seke Rural Home Based Care is also in the process of introducing a savings and land project for caregivers.

In South Africa, with 1395 Alliance members, there was no mention new programs for caregivers although there were new steps towards "re-engineering the public healthcare system" and a National Health Insurance Policy. However "discussions held at the top levels are not including the care-givers at the grassroots" in spite of the fact that "caregivers are involved or take part when the implementation takes place." With respect to caregiver finance "those registered are given stipends, material support, training such as bookkeeping, project management and reporting." This may refer to the fact, that the government provides stipends for 500 caregivers but that it is "not a reliable source of income because it does not come regularly". While "formal" caregivers take part in some training and other programs, "controlling officials put limitations to the number of groups to take part in those programs".

For Malawi, with the lowest number of regional Alliance members, no finance programs were reported and no specific response was given to the issue of additional types of supports for caregivers. With respect to new programs and policies related to caregiving, hospitals and clinics have introduced a new standard set of guidelines established by the Ministry of Health. These guidelines standardize clinical management of HIV positive clients. Problems of illiteracy may be reflected in the fact that while, "caregivers are aware of these new policies, only a few know what they mean and understand them".

Finally, for East Africa, Kenya, with one of the highest levels of Alliance membership across the continent, reported a finance program for caregivers, although the initiative seems to be limited to "a few elderly caregivers and youth" who are receiving cash transfers in a pilot initiative which the government agreed to expand following pressure from Groots, Kenya, the Alliance coordinating organization. It was stated that there was "a lot still pending" and that remuneration was "challenging because the government budget only provided for 10 out of 50 caregivers with little paid out because the government was still deciding how to allocate funding." With respect to new policies, the Ministry of Public Health has also held discussions on standardizing home based care training manuals and allocating caregivers to health facilities. Fifty CHWs have been trained for the 210 constituencies in the country and some have been attached to Health Facilities. There is also government will to establish a Kenya AIDS Trust Fund and civil society has been lobbying the government on an HIV and AIDS act to legitimize advocacy for improved treatment and care.

In Uganda while there are no financing programs, "a small percentage of caregivers have received support from the National Agricultural Advisory Services programs.[of] goats, seed, chicken rearing and material support such as protective gear". New policies of relevance for caregivers includes the fact that for "infants born of HIV positive mothers, babies are put on ARV's while they continue breast feeding for the first six months and [are]thereafter put on supplement feeding for up to one year".

Finally, in Rwanda, where Alliance membership data was not provided, "funding is sparse for home-based caregivers" but new policies include "the integration of community health workers, who are encouraged to join a cooperative". Another new policy which caregivers were reported to be generally aware of was the "Palliative Care Policy, which regulates morphine use and provides the terminally ill with consistent access to medication and home-based care".

Health System Strengthening

Respondents were next probed on their views about important issues in the broader health policy environment of interest to caregivers in their countries occurring around "health system strengthening" defined as a central goal by the World Health Organization (WHO, 2007).

As see in Table 1.4 no response was received from Alliance representatives in Nigeria or Malawi however most countries report some interesting developments. In a number of the countries, new efforts towards health system strengthening are involving steps such as increased liberalization, creation of more private sector clinics, strengthening capacity of health personnel on AIDS management, sometimes reduced costs of ARV treatment, or building or transferring more skills to dispersed health centers because of transportation challenges. Trends such as these are reported in Cameroon, Benin, Rwanda and Uganda.

In some cases more government regulation and oversight was evident. For example in Cameroon mention was made of efforts to better organize and regulate the practice of traditional medicine to "get rid of quacks", with some increased assistance also given for traditional practitioners. In Benin it was noted that the areas in which caregivers can operate is being more carefully delineated by the government. In Uganda, in addition to building more clinics, the government has "taken full responsibility of community health systems available".

Outreach efforts are being strengthened in countries such as South Africa, where outreach teams are being used to strengthen community health workers. This is presenting challenges for caregivers since the process is not "leaving much room for caregivers" although civil society is demanding that two caregivers be included in each of the outreach teams at the ward level. In Uganda, "Village Health teams are being trained by government and other partners in various health related issues to strengthen community participation in health planning and to hold service providers accountable."

Challenges to health personnel are being compensated in some countries like Kenya by the fact that the government "has recognized that task shifting [is] one of the ways to strengthen health system". This refers to "attachment of community health workers" which has been "embraced as one of the strategies to achieve task shifting by leveraging human resources". In some countries NGO's and donors are clearly playing an important role. For example in Kenya at the community level "many partners ... are shifting a lot of funds to community based organizations at the grassroots level" and "although this is where the focus should be, many still do not have capacity to sustain such partnerships". In Zambia at the community level a culture of self-help and group engagement was still strong due to the realization that "little external assistance is available." Groups contribute money, buy food, medicine or provide transport to sick patients. Home-based caregivers were also reporting contributing on a regular basis from their own resources to meet the needs of clients most in need. In addition, communities sometimes finance income generating activities to support health and economic needs of those living with HIV.

In some countries, new collaborations and interesting roles are reported for home-based caregivers. For example in Zimbabwe:

   School Health Assessment programs are one of the
   health interventions [carried out] by Seke Rural
   Home-Based Care. This is where schools are
   mobilized for the 'head to toe' health assessment
   for every enrolled child. This exercise is
   implemented in conjunction with the Ministry of
   Health. All children are physically checked for any
   signs of illness and those suspected of HIV
   infection will be encouraged to be tested in
   consultation with the parents and guardians.

This is of significance because caregivers are playing an important role in the collaboration by mobilizing the community, identifying ill looking children and encouraging parents to have children tested at local health centers.

[FIGURE 1 OMITTED]

The survey next turned to the issue of caregiver advocacy, questioning survey respondents about what caregivers are advocating for in each of the various countries. As we see from Fig. 1 additional resources for caregivers, recognition for caregivers and increased involvement of caregivers in decision-making were the most frequently cited issues of concern mentioned, with each of these cited by respondents from five countries.

Additional resources were an advocacy issue for Cameroon, Nigeria, South Africa, Malawi and Uganda. This involves advocacy for resources including basic materials, drug access (ARV and others), education, training and mobile clinics. Greater caregiver involvement in decision-making was the issue mentioned by respondents in Cameroon, Kenya, South Africa, Malawi and Uganda while increased caregiver recognition was the theme highlighted by Cameroon, Malawi, Zimbabwe, Uganda and Zambia. Increased caregiver compensation or grant funding was the focus of advocacy in four countries including Cameroon, South Africa, Malawi and Zambia.

SUMMARY AND RECOMMENDATIONS

In addition to the surveys, in March, representatives from the Alliance from seven countries including Ghana, Kenya, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe participated in conference calls to reflect on emerging trends in relation to health and caregiving in Africa and to make a series of recommendations as a follow up to the survey. These discussions helped to further clarify some of the issues raised above. During those discussions, three primary issues were emphasized:

* Decentralizing health systems is changing local realities of caregivers

It was clear from the discussion that respondents felt that caregivers are either not included, or only included selectively in various government programs with resources involved. For example, in Zambia and Benin caregivers are by-passed for training while in Zimbabwe only two of the 1,300 community health workers are also caregivers in the Alliance who are formally recognized by receiving government salaries. In Ghana although community health workers receive salaries and government benefits no Alliance home-based caregivers are formally considered to be community health workers (CHWs).

The problem in many cases is that new people are being recruited into the ranks of community health workers rather than governments working with those individuals already providing home-based care. Caregiver groups attempting to be included in these programs are being "given the run around" by governments and asked to go through complex and exclusionary processes to access these programs. For example in South Africa the government has a complicated training process on project management and bookkeeping however individuals must be registered and meet certain requirements to qualify.

In addition, caregivers formalized into the system are either not supported financially or are supported only with extremely small stipends in spite of the fact that individuals are being asked to take on more and more responsibilities without any type of pay increase. Examples include Uganda where caregivers are on Village Health Teams but receive no stipend, Ghana where caregivers receive a $100 a year stipend with an increase only once over three years. In Nigeria caregivers are now being asked to be at hospitals all day by the government and are taking care of hundreds of referrals but are not formally considered as "health workers" so only receive a small stipend. They are also being asked to run orphans and vulnerable children (OVC) programs with these same limited resources. In Kenya while caregivers are starting to be given individual stipends by the government the home-based care Alliance members worry that the channeling of funds through individual stipends may impede collective organizing. They argue that moving funding through the Home-based Care Alliance through grants would strengthen grassroots cooperation and leadership

* Caregiver work is changing with increased ARV treatment and decentralization of health systems

Caregivers are now taking on work in clinics and hospitals however programs are often shifting responsibilities of community health workers away from AIDS towards more of a focus on overall health. For example in Nigeria caregivers are serving as "site coordinators" at hospitals and take referrals while in Zambia they are now working in clinics. In Zimbabwe they are being asked to weigh babies at the expense of more training on either HIV or home-based care while in Ghana they are being trained as nurse assistants at the same time that referrals are given to caregivers if someone tests positive. In Cameroon caregivers are also being used to distribute mosquito nets related to malaria control.

* Caregivers burnout and lack of support is greater than ever and experienced across all members

It was noted that contextual factors include the fact that government budgets for AIDS are stagnant or falling. This includes the fact that some countries have had AIDS money suspended, government corruption in relation to these funds is a major problem and money is not devolving from national budgets to the local level and bilateral agencies such as USAID, PEPFAR, and the Global Fund for AIDS are shifting priorities and presence.

Groups within the network of the Home-based Care Alliance also have limited capacity to analyze budgets and plans and negotiate for more caregiver resources and recognition. Groups also were not using a consistent approach and benchmarks for counting of the caregivers or "friends" they support. Some of the strategies groups in the network are using include conducting research on the changing face of AIDS, pushing for representation of caregivers on various bodies such as constituency, state and national AIDS Councils, District Health Forums and other decision-making bodies.

In addition they are organizing, mobilizing and building leadership structures to improve negotiation with decision-makers and active participation in meetings. They are also using advocacy strategies focusing on negotiating for resources such as those needed to build community run social protection schemes like community gardens and are targeting specific budget lines to negotiate for funds to be directed towards community-led initiatives. A final recommendation was the need for formalizing and registering Alliances both locally and national in order to access government programs at all levels.

REFERENCES

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Asaki, B. (2012, August 8) Interview by Ransom, P. Huairou Commission, Brooklyn N.Y.

Babigumira, J. B., Sethi, A. K., Smyth, K. A., & Singer, M. E. (2009). Cost effectiveness of facility-based care, home-based care and mobile clinics for provision of antiretroviral therapy in Uganda. Pharmacoeconomics, 27(11), 963-973.

Boryc, K., Anastario, M. P., Dann, G., Chi, B., Cicatelli, B., Steilen, M., Gordon-Boyle, K., Morris, M. (2010). A needs assessment of clients with HIV in a homebased care program in Guyana. Public Health Nursing, 27(6), 482-491. doi:10.1111/j.1525-1446. 2010.00888

Bowie, C., Gondwe, N., & Bowie, C. (2010). Changing clinical needs of people living with AIDS and receiving home-based care in Malawi--the Bangwe Home-based Care Project 2003-2008--a descriptive study. BMC Public Health, 10, 370-381. doi:10.1186/1471-2458-10-370

Family Health International (2004). Module 4 monitoring and evaluating community home-based care programs. In Monitoring HIV/AIDS programs: Participant guide. Retrieved from http://gametlibrary.worldbank.org/FILES/542_Moni toring%20Community%20HomeBase%20Care%20 -%20participant%20%20FHI%20Module%204.pdf.

Greenberg J. (2012) Past due: Remuneration and social protection for caregivers in the context of HIV and AIDS. Policy Briefing. UK Consortium on AIDS and International Development. Retrieved from http://aidsconsortium.org.uk/wp-content/uploads/2011/11/UK-AIDS-Consoritum-policy-briefing-remuneration-of- caregivers.pdf

Groots International (2009). Grassroots women caring for HIV/AIDS-affected communities. Brochure. Brooklyn: N.Y.

Hayes S. (2008) The Home-based Care Alliance: Caregivers take leadership. Common Concern. 138, 16-18. Retrieved from http://www.huairou.org/sites/default/files/Common %20Concern-Home%20Based%20Care%20Alliance.pdf

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ProCAARE. (2001) Gabarone Declaration on Community Home-Based Care. Retrieved from http://www.procaare.org/archive/procaare/200108/ msg00005.php

Ramashwar, S. S. (2010). Ugandan trial suggests home-based HIV care is effective and reduces costs. International Perspectives on Sexual & Reproductive Health, 36(1), 50. Retrieved from http://www.guttmacher.org/pubs/journals/3605010a .html

Schneider, H. H., & Lehmann, U. U. (2010). Lay health workers and HIV programmes: implications for health systems. AIDS Care, 2260-67. doi:10.1080/09540120903483042

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PAMELA E. RANSOM

Metropolitan College

BECCA ASAKI

Huairou Commission

Table 1.1

West African Home-Based Care Policies and Programs

Country                  Programs               New Policies

Nigeria                  --HBC finance          --None
# Alliance caregivers:   --HBC social
910                        protection,
# cared for: 2730          material support,
NGO Coordinator:           transport stipends
IWCC

Benin                    --No HBC finance       --Lack of
# Alliance caregivers:   programs                 organization/
405                      --Some regional          gov't
# cared for: NR            training volunteer     recognition
Coordinator: Lambassa      mediators

Cameroon                 --No HBC finance       --Pilot gov't
# Alliance caregivers:     programs               HBC program
2000 (est.)              --Sporadic civil       --National
# cared for: NR            society programs       program care
Coordinator: Ntanka      --Referral program       OVC

Table 1.2

South African Home Based Care Policies and Programs

Country                  Programs                 New Policies

Zimbabwe                 --HBC finance provided   --10 year HBC
                                                  Policy
# Alliance caregivers:
1571                     --ISALProject-           --Seke HBC writing
# cared for: 5136        savings/land project     HBC policy

Coordinator: Groots

Zimbabwe/Seke

South Africa             --Stipends for           -Reengineering
                         registered caregivers    health system
# Alliance caregivers:
1395                                              --Not including
                                                  caregivers
# cared for: 18,000

Coordinator: Lamosa

Malawi                   --No HBC finance         --Standardized
                                                  guidelines
# Alliance caregivers:   programs                 that few caregivers
681                                               understand

# cared for: NA
Coordinator: CCODE

Zambia                   --No HBC finance         -No new policies
                         programs
# Alliance caregivers:
3082                     --Cooperating partners
                         give training/tools
# cared for 11,406

Coordinator: People
Process (PPHPZ)

Table 1.3

East African Home-Based Care Policies and Programs

Country                     Programs              New Policies

Kenya                       --HBC finance         ---Discussions
# Alliance caregivers:      given                 standard HBC
                                                  training/caregiver
12,000                      --Elderly caregiver   allocation/
# ared for: no total-7552   cash transfers        remuneration
OVC                         --Much pending
Coordinator: Groots Kenya

Rwanda                      --Funding sparse      --Integration CHWs
# Alliance caregivers: NR   for HBC               --Palliative
# cared for: NR                                   Care Policy
Coordinator: Rwanda
Women's Network

Uganda                      --No HBC finance      --ARV to infants
# Alliance caregivers:      --Small % get         --Few caregivers
3745                        support               aware
# cared for: 40497          agricultural
Coordinator:                programs
UCOBAC/AWARE/SWID

Table 1.4

Policy Environments and Health System Strengthening

WEST                       EAST                  SOUTH

Cameroon   -Traditional/   Kenya    -Task        Zimbab   -School
           formal                   Shifting     we       Health
           health                                         Assessment/
           system                                         focus on
           collaboration                                  children
           regulation

           --More
           health
           personnel

           --Village
           mobile
           clinics
           and
           increased
           private
           sector role

Nigeria    --No            Uganda   --Village    South    --Outreach
           Response                 Health       Africa   Teams
                                    Teams

Benin      --HBC           Rwanda   --More       Malawi   --No
           spheres                  health                response
           delineated               centers/
                                    cooperates
           --Skills
           transfers
           to health
           centers

           --Problems
           financial
           support
           and
           caregiver
           access

                                                 Zambia   --Middle
                                                          Out
                                                          approach