Orphans and Vulnerable Children in sub-Saharan Africa

Orphans and Vulnerable Orphans and Vulnerable Children in sub-Saharan Children in sub-Saharan

AfricaAfrica

Tonya Renee Thurman, MPH, Tonya Renee Thurman, MPH, PhDPhD

Social Impact of AIDS Social Impact of AIDS Class lecture, April 11Class lecture, April 11thth 2008 2008

OverviewOverview

Who are OVC?Who are OVC? Terminology Terminology DefinitionsDefinitions Prevalence & estimationsPrevalence & estimations Evidence of “vulnerability”Evidence of “vulnerability”

Considerations for programmingConsiderations for programming Targeting OVCTargeting OVC Key Strategies and ConsiderationsKey Strategies and Considerations What works?What works? Way ForwardWay Forward

TerminologyTerminology

AIDS OrphansAIDS Orphans

CABA (Children Affected by AIDS)CABA (Children Affected by AIDS)

Orphans & Vulnerable Children Orphans & Vulnerable Children (OVC)(OVC)

Who are VC?Who are VC?

The definition of “Vulnerable children” The definition of “Vulnerable children” influenced by donor priorities and often influenced by donor priorities and often tend to refer to children affected by HIV tend to refer to children affected by HIV and AIDS, such as:and AIDS, such as:

Children living with caregivers who are Children living with caregivers who are chronically ill, possibly due to chronically ill, possibly due to HIV/AIDS;HIV/AIDS;

Children who are HIV positive Children who are HIV positive Children living with their parents in Children living with their parents in

fostering households, which may have fostering households, which may have recently taken in an orphaned childrecently taken in an orphaned child

Definition of VC Definition of VC An example from the fieldAn example from the field

USAID South Africa defines the “V” as those who USAID South Africa defines the “V” as those who are more vulnerable because of any or all of the are more vulnerable because of any or all of the following factors following factors that result from HIV and AIDSthat result from HIV and AIDS : : Is HIV-positiveIs HIV-positive Lives without adequate adult support (e.g., in a Lives without adequate adult support (e.g., in a

household with chronically ill parents, a household household with chronically ill parents, a household that has experienced a recent death from chronic that has experienced a recent death from chronic illness, a household headed by a grandparent, and/or illness, a household headed by a grandparent, and/or a household headed by a child);a household headed by a child);

Lives outside of family care (e.g., in residential care or Lives outside of family care (e.g., in residential care or on the streets); oron the streets); or

Is marginalized, stigmatized, or discriminated against.Is marginalized, stigmatized, or discriminated against.

Definition of VC Definition of VC An example from the fieldAn example from the field

USAID South Africa goes on to say: USAID South Africa goes on to say: ““This operational definition identifies those who This operational definition identifies those who

are potentially eligible for services, but does not are potentially eligible for services, but does not identify those most in need of services. To inform identify those most in need of services. To inform programmatic decisions, each community and programmatic decisions, each community and program will need to prioritize those children program will need to prioritize those children most vulnerable and in need of further care.” most vulnerable and in need of further care.”

More flexibility to allow OVC to include children More flexibility to allow OVC to include children whose parents are alive but who live with whose parents are alive but who live with relatives or non-relatives relatives or non-relatives under strained under strained capacitycapacity;;

Thus, the V becomes a very lumpy and catch-all Thus, the V becomes a very lumpy and catch-all termterm

Orphan Definition Orphan Definition American Heritage Dictionary defines an American Heritage Dictionary defines an

orphan as “a child whose parentorphan as “a child whose parentss are are dead.” dead.”

Internationally recognized definition of an Internationally recognized definition of an orphan is: “a child age 0-17 years old orphan is: “a child age 0-17 years old who has lost one or both parents”who has lost one or both parents”

Single orphan – a child who has lost one parent.Single orphan – a child who has lost one parent. Double orphan – a child who has lost both parents.Double orphan – a child who has lost both parents. Maternal orphan – a child whose mother has died Maternal orphan – a child whose mother has died

(includes double orphans).(includes double orphans). Paternal orphan – a child whose father has died Paternal orphan – a child whose father has died (includes double orphans).(includes double orphans).

Prevalence of Orphans Prevalence of Orphans

~ Hordes of Orphans ~~ Hordes of Orphans ~

In developing countries: In developing countries: 132.7 million orphans across Asia, Latin America 132.7 million orphans across Asia, Latin America

and sub-Saharan Africa (SSA)and sub-Saharan Africa (SSA)

In sub-Saharan Africa:In sub-Saharan Africa: 48.3 million orphans 48.3 million orphans

12% of all children age 0-1712% of all children age 0-17

9.1 million are “double orphans” 9.1 million are “double orphans”

(Unicef, 2005 estimates)(Unicef, 2005 estimates)

Cause of OrphanhoodCause of Orphanhood

Total Total number of number of orphans orphans

% of % of children children who are who are orphansorphans

Number of Number of orphans orphans due to due to AIDSAIDS

Children Children orphaned by orphaned by

AIDS as % of all AIDS as % of all orphansorphans

Cote Cote d’Ivoired’Ivoire

1,400,0001,400,000 1515 450,000450,000 3333

Central Central African African RepublicRepublic

330,000330,000 1616 140,000140,000 4141

SwazilandSwaziland 95,00095,000 1717 63,00063,000 6666

ZimbabwZimbabwee

1,400,0001,400,000 2121 1,100,0001,100,000 7777

Source: UNAIDS and UNICEF Estimates, 2006

Over 12 million children in SAA have been orphaned by AIDS

Percent Orphaned by AIDS and Other Percent Orphaned by AIDS and Other CausesCauses

Source: UNAIDS and UNICEF Estimates, 2006

0% 5% 10% 15% 20% 25%

Zimbabwe

Zambia

Botswana

Lesotho

Swaziland

Central African Republic

Rwanda

Cote d'Ivoire

Mozambique

Malawi

AIDS

AllOtherCauses

““Orphans became “shorthand” for Orphans became “shorthand” for

the cumulative community impact of the cumulative community impact of AIDSAIDS

Foster 2006

The increase in orphans lags HIV The increase in orphans lags HIV prevalence by about 10 yearsprevalence by about 10 years

0

5

10

15

20

25

30

1980 1985 1990 1995 2000 2005 2010

HIV prevalence

orphans

In many African countries,even if new infections leveled by the year 2000...

In many African countries,even if new infections leveled by the year 2000...

Infection rates will remain high Infection rates will remain high through at least 2010through at least 2010

Deaths will not level until 2020Deaths will not level until 2020

The proportion of children orphaned will be The proportion of children orphaned will be unusually high through at leastunusually high through at least 20302030

Estimating numbers of Estimating numbers of OOVCVC

Number of Orphans (maternal, paternal Number of Orphans (maternal, paternal and double) has been more accurate and and double) has been more accurate and more readily available.more readily available.

Rely on demographic & epidemiological Rely on demographic & epidemiological datadata

Sources include: Demographic Health Sources include: Demographic Health Survey, Multiple Indicator Cluster Survey, Multiple Indicator Cluster Surveys, Census Data, Birth/Death Surveys, Census Data, Birth/Death RegistrationRegistration

Estimating numbers of Estimating numbers of OOVCVC

Some Basics: Some Basics: Different methodologies for calculating Different methodologies for calculating

estimates and projectionsestimates and projections Factors considered include:Factors considered include:

HIV prevalenceHIV prevalence Adult MortalityAdult Mortality Fertility ratesFertility rates Size of child populationSize of child population Marriage and reproductive patterns Marriage and reproductive patterns Vertical transmission ratesVertical transmission rates

Total orphans = maternal orphans + Total orphans = maternal orphans + paternal orphans - double orphans.paternal orphans - double orphans.

Details on modeling and projections can be found in UNICEF, 2006 Annex & Details on modeling and projections can be found in UNICEF, 2006 Annex & work by Grassly et al.work by Grassly et al.

Estimating numbers of Estimating numbers of OOVVCC

Vulnerability concerning HIV/AIDSVulnerability concerning HIV/AIDS In Zambia, for example, 11.8 per cent of In Zambia, for example, 11.8 per cent of

children were vulnerable in 2005:children were vulnerable in 2005: They either lived in a household with a They either lived in a household with a

chronically ill adult, had a chronically ill chronically ill adult, had a chronically ill parent living outside the household, or had parent living outside the household, or had experienced an adult death in their household experienced an adult death in their household in the last year (UNICEF 2006)in the last year (UNICEF 2006)

Child-headed householdsChild-headed households Large demographic surveys do not show Large demographic surveys do not show

any substantive numbers of CHH.any substantive numbers of CHH.

Estimating numbers of Estimating numbers of OOVVCC

But, how to estimate or measure But, how to estimate or measure the number of “vulnerable” beyond the number of “vulnerable” beyond this has been more problematic.this has been more problematic.

Not all definitions can be Not all definitions can be measured, so USAID has started to measured, so USAID has started to look at definitions that can be look at definitions that can be supported by data. supported by data.

Current Efforts towards Current Efforts towards total numbers of OVC total numbers of OVC

(LaTour, USAID Office of the Global AIDS Coordinator, NIH/USAID OVC Mtg, 2008)

OVC Estimates: Model 1OVC Estimates: Model 1

Current Efforts towards Current Efforts towards total numbers of OVCtotal numbers of OVC


Why do we care?Why do we care?

Larger numbers are good for advocacy Larger numbers are good for advocacy and bringing attention to the need for and bringing attention to the need for services and resources.services and resources.

However, the larger number reduces However, the larger number reduces coverage rates significantly. This could coverage rates significantly. This could have negative consequences at a policy have negative consequences at a policy level. level.

All numbers have different implications All numbers have different implications for planning appropriate programs. for planning appropriate programs.

Global estimates: Global estimates: ConsiderationsConsiderations

RegionRegion % of all % of all childrenchildren

Total NumberTotal Number

AfricaAfrica 1212 5.5 million5.5 million

AsiaAsia 66 8 million8 million

NigeriaNigeria 1313 9.6 million9.6 million

KenyaKenya 1313 2.3 million2.3 million

BotswanaBotswana 1919 150,000150,000

SwazilandSwaziland 1717 95,00095,000

Absolute numbers vs Percentages


How orphan and/or vulnerable is How orphan and/or vulnerable is defineddefined What type of “O?” Who are the “V?” Is it What type of “O?” Who are the “V?” Is it

just “O” or OVC? just “O” or OVC?

Age of populationAge of population Almost half of all orphans and two Almost half of all orphans and two

thirds of double orphans are thirds of double orphans are adolescents ages 12–17 adolescents ages 12–17 (Unicef 2006 ).(Unicef 2006 ).

Some profiles are limited to certain age Some profiles are limited to certain age groups (e.g., 0-14 yrs)groups (e.g., 0-14 yrs)


Rarely provide gender profileRarely provide gender profile Global statistics often not disaggregated by Global statistics often not disaggregated by

gendergender

Data sourceData source Availability, accuracy, representativeness Availability, accuracy, representativeness Different data, methods, and assumptions Different data, methods, and assumptions

used by different organizationsused by different organizations Are we capturing the most vulnerable? (e.g., Are we capturing the most vulnerable? (e.g.,

street kids, those in institutions, migrant & street kids, those in institutions, migrant & refugee children, CHH missed in household refugee children, CHH missed in household based surveys)based surveys)

Evidence of Evidence of “vulnerability”“vulnerability”

Images are Images are often negativeoften negative

Pull at the Pull at the heartstringsheartstrings

Picture of Picture of sadness –only sadness –only smile when…..smile when…..

Peter Ouma, an orphan in Nyalenda slum, Kisumu, Kenya, cries after falling, 2006. Photo by Paul Di Stephano, courtesy of Photoshare.

Problems commonly associated Problems commonly associated w/ OVCw/ OVC

Problems commonly associated Problems commonly associated w/ OVCw/ OVC

REDUCEDREDUCED INCREASEDINCREASED Food intake Food intake MalnutritionMalnutrition Health care Health care Ill healthIll health SchoolingSchooling Workload, labourWorkload, labour Safety, stabilitySafety, stability Migration, distressMigration, distress NurtureNurture Exploitation, abuseExploitation, abuse Identity, securityIdentity, security HomelessnessHomelessness Love & affectionLove & affection Abandonment, Abandonment,

rejectionrejectionAdjustmentAdjustment MaladjustmentMaladjustmentProtectionProtection Vulnerability to Vulnerability to infectioninfectionInclusionInclusion ExclusionExclusion

(Richter, 2006)

Evidence of vulnerabilityEvidence of vulnerability Most available data concerns orphansMost available data concerns orphans

Little research as to the vulnerability of the Little research as to the vulnerability of the other types of aids affected “V” groupother types of aids affected “V” group

Most data concerning issues facing Most data concerning issues facing children living with an HIV parent is from children living with an HIV parent is from low prevalence countries, and even then:low prevalence countries, and even then:

““Current evidence base is too Current evidence base is too geographically geographically limited with limited with insufficient evidence of the underlying insufficient evidence of the underlying causal relationships to allow for causal relationships to allow for generalizable generalizable conclusions about the conclusions about the situation of children affected situation of children affected by by HIV/AIDS” HIV/AIDS” (Lynne Franco, NIH/USAID OVC Mtg, 2008)(Lynne Franco, NIH/USAID OVC Mtg, 2008)

Evidence of Evidence of Vulnerability: OVulnerability: OVVCC

Issues facing children living with an Issues facing children living with an ill caregiverill caregiver

Psychosocial problemsPsychosocial problems Burden of taking care of family Burden of taking care of family

membermember Watch parents suffer and die.Watch parents suffer and die. Worry about the future.Worry about the future. Fear they are infectedFear they are infected Depression, Anxiety Depression, Anxiety (Stoppelbein, 2000)(Stoppelbein, 2000)

Minimal parent-to-child discussion Minimal parent-to-child discussion worry in silence. worry in silence.


Issues facing children living with an ill Issues facing children living with an ill caregivercaregiver

Education Education School withdrawal, poor attendanceSchool withdrawal, poor attendance

Tanzania: Reduced hours in months previous to parent death in Tanzania (Ainsworth, Beegle, Koda2005)

Kenya: Maternal: 6.6 percentage point drop in attendance in 1-2 years before death (2/3 of total effect) in Kenya (Evans & Miguel 2007)

Kenya: Children in households with parents just starting ARV attend 10% fewer hours of school per week in [Treatment reduces that to 2%] (Zivin, Thirumurthy, & Goldstein 2007)

Other potential risks Other potential risks Economic hardshipEconomic hardship Increased risk of HIV infection?Increased risk of HIV infection?


Impact of DisclosureImpact of Disclosure Remains an empirical questionRemains an empirical question Likely related to treatment availability Likely related to treatment availability

and child developmental stageand child developmental stage

Children living with HIVChildren living with HIV Little is known about adherence and Little is known about adherence and

illness management skillsillness management skills Risk reduction will become important Risk reduction will become important

with sexual debutwith sexual debut

Evidence of vulnerability: Evidence of vulnerability: OOVC VC

With whom do orphans live?With whom do orphans live?

Majority of orphans are living with surviving Majority of orphans are living with surviving parent parent Counters the widely held myths about Counters the widely held myths about

orphaning in Africaorphaning in Africa

Many children now in permanent care of Many children now in permanent care of extended kin. extended kin.

Children more in care of maternal kin Children more in care of maternal kin in paternal societies this can be associated with in paternal societies this can be associated with

stigma, loss of property etc. stigma, loss of property etc.

With whom do orphans With whom do orphans live?live?

With whom do orphans With whom do orphans live?live?

InstitutionsInstitutions At least >127,000 in East Africa living in At least >127,000 in East Africa living in

institutions institutions (grossly underestimated)(grossly underestimated) In Zimbabwe:In Zimbabwe: 50% of those living in 50% of those living in

institutions have at least one parent aliveinstitutions have at least one parent alive In Ghana: 80% in institutions have existing In Ghana: 80% in institutions have existing

families. families. In Swaziland: “Many” go home to family on In Swaziland: “Many” go home to family on

weekendsweekends

(Greenberg, NIH/USAID OVC Mtg, 2008)(Greenberg, NIH/USAID OVC Mtg, 2008)

Evidence of vulnerability: Evidence of vulnerability: OOVCVC

Orphans and psychosocial issuesOrphans and psychosocial issues Consistently negative outcomes for Consistently negative outcomes for

internalizing symptoms internalizing symptoms (Sherr, in press)(Sherr, in press)

Sibling separation, bereavement & loss Sibling separation, bereavement & loss of affection are sources of distressof affection are sources of distress

Lack of standardized or consistent Lack of standardized or consistent measurementsmeasurements

Little evidence of behavioral problemsLittle evidence of behavioral problems

Orphans and abuseOrphans and abuse Principally anecdotal Principally anecdotal


Orphans and educationOrphans and education 102 surveys in 51 countries, 58% deficits for 102 surveys in 51 countries, 58% deficits for

double orphans double orphans (Ainsworth & Filmer, 2006)(Ainsworth & Filmer, 2006)

19 DHS surveys in 10 countries found significantly 19 DHS surveys in 10 countries found significantly lower enrollment rates lower enrollment rates (Case et al. 2003)(Case et al. 2003)

UNICEF analysis in 24 countries also found wide UNICEF analysis in 24 countries also found wide varionation; as does another 6 papers on 7 varionation; as does another 6 papers on 7 countriescountries

Orphans and HIV riskOrphans and HIV risk Two studies in Zimbabwe documented a higher Two studies in Zimbabwe documented a higher

rate of reproductive health problems among rate of reproductive health problems among adolescent girls who are orphans than among non-adolescent girls who are orphans than among non-orphan girls orphan girls (Gregson) (Gregson)

Earlier sexual onset for females in Zimbabwe & Earlier sexual onset for females in Zimbabwe & among males and females in South Africa among males and females in South Africa (Gregson; (Gregson; Thurman)Thurman) (Adato, NIH/USAID OVC Mtg, 2008)(Adato, NIH/USAID OVC Mtg, 2008)


Orphans and food security/nutritionOrphans and food security/nutrition 8 studies find orphans worse off8 studies find orphans worse off CHS data from 6 southern African countries CHS data from 6 southern African countries

found no disadvantage found no disadvantage (C-SAFE/WFP)(C-SAFE/WFP)

New DHS data analysis from 5 ESA countries New DHS data analysis from 5 ESA countries finds wealth meain predictor of nutrition, but finds wealth meain predictor of nutrition, but discrimination under certain circumstances in discrimination under certain circumstances in 3 countries 3 countries (Stewart 2007)(Stewart 2007)

Orphans and povertyOrphans and poverty 10 studies poorer HHs, 21 studies richer HH 10 studies poorer HHs, 21 studies richer HH

(Ainsworth et al 2006)(Ainsworth et al 2006)

New DHS data analysis from 5 ESA countries: New DHS data analysis from 5 ESA countries: orphans not represented in poorest HHs orphans not represented in poorest HHs found found (Stewart 2007)(Stewart 2007)

(Adato, NIH/USAID OVC Mtg, 2008)(Adato, NIH/USAID OVC Mtg, 2008)

What do we conclude?What do we conclude?Evidence of vulnerability: Evidence of vulnerability:

OOVCVCIt depends! It depends! On:On: Poverty: major determinant Poverty: major determinant Household structure: blended HHs Household structure: blended HHs

or not; relationship of orphans to HH or not; relationship of orphans to HH head, age, whether mother deceasedhead, age, whether mother deceased

Uncontrolled external factors: Uncontrolled external factors: Nature & extent of a particular need Nature & extent of a particular need

can vary by time & placecan vary by time & place


OOVCVCWait, who are we talking about Wait, who are we talking about here?here?

DemographicsDemographics Age?Age? Gender?Gender? Orphan group compounded with HIV disease?Orphan group compounded with HIV disease?

Type of orphanType of orphan Cause of parental death?Cause of parental death? Single? Double? Maternal? Paternal? Single? Double? Maternal? Paternal?

Empirical Definition of Empirical Definition of OrphansOrphans

Systematic Systematic review of review of psychological psychological and health and health issues among issues among orphans orphans affected by affected by AIDSAIDS

383 studies 383 studies includedincluded

1%2%

6%3%

17%

71%

Orphan NotDefined

One or BothParents

Double

Maternal

Paternal

Other

(Sherr in press)

Empirical definitions of Empirical definitions of orphansorphans

Research concerning orphans:Research concerning orphans: Lack of standardized definitions of Lack of standardized definitions of

orphans and inclusion of orphans and inclusion of paternal/maternal orphanspaternal/maternal orphans

Variance in cut-off ages (15 to 19)Variance in cut-off ages (15 to 19)

No data from any study could be verified No data from any study could be verified accurately against data from another accurately against data from another studystudy

(Sherr, in press)(Sherr, in press)


OOVCVC

Father figures: the progress at school of Father figures: the progress at school of orphans in South Africaorphans in South Africa

““If two studies in the same province of South If two studies in the same province of South Africa disagree as to whether the death of the Africa disagree as to whether the death of the father, as well as the mother, impacts directly father, as well as the mother, impacts directly on the progress children make in their on the progress children make in their schooling, we lack the knowledge needed to schooling, we lack the knowledge needed to prescribe solutions for Africa as a whole.”prescribe solutions for Africa as a whole.”

(Timaeus& Boler, 2007)(Timaeus& Boler, 2007)


OVCOVC More data is needed with adequate controls & definitionsMore data is needed with adequate controls & definitions

Need targeted samples or very large samplesNeed targeted samples or very large samples

Orphan Orphan StatusStatus

N = N = 3,5043,504

PercentPercent

MaternalMaternal 176176 55

PaternalPaternal 318318 1010

DoubleDouble 3636 11

Mom illMom ill 295295 99

Dad illDad ill 202202 66

Both illBoth ill 5353 22

(OVC TE Kenya Data, Thika, 2007)

An example from the field


OVCOVC Need increased understanding of the causal Need increased understanding of the causal

pathways pathways

Are we spending too much time making the Are we spending too much time making the case that orphans are a risk group?case that orphans are a risk group? Bias towards comparing orphans and non-orphansBias towards comparing orphans and non-orphans

Absolute size of impact may be small compared to other gaps: (e.g., Urban/rural & Poverty) No where were orphans 100% No where were orphans 100%

Enough evidence to require attention to Enough evidence to require attention to orphans; not enough evidence to target orphans; not enough evidence to target orphans exclusively orphans exclusively

Child VulnerabilityChild VulnerabilityChild VulnerabilityChild VulnerabilityIs determined by:• history• prevailing conditions• personality/temperament• support• arrangements post-disturbance etc

MOST ESPECIALLY BY PARENTAL SUPPORT /

DISRUPTION

- Not necessarily by a particular experience or membership of a specific

category

(Richter, 2006)

Targeting OVC ProgramsTargeting OVC Programs

Targeting ProgramsTargeting Programs

Age ConsiderationsAge Considerations

OVC are defined as under age 18OVC are defined as under age 18 No longer vulnerable at 18?No longer vulnerable at 18? Age verification difficultAge verification difficult

Tendency towards serving primary Tendency towards serving primary age groupage group Quick fixQuick fix Majority of orphans are adolescentsMajority of orphans are adolescents


Unintended Consequences for OVCUnintended Consequences for OVC

Increasing their vulnerability Increasing their vulnerability StigmatizationStigmatization Preferential treatment can cause Preferential treatment can cause

jealousiesjealousies Higher marginalizationHigher marginalization Community members aim to be Community members aim to be

eligible for serviceseligible for services Community members forsake Community members forsake

responsibility of OVC to NGOs responsibility of OVC to NGOs


Labeling children as OVCLabeling children as OVC People at the community level often pick up People at the community level often pick up

labels from agency documents, discussions, and labels from agency documents, discussions, and presentations and begin to use them. presentations and begin to use them.

Learning to use the same jargon as those who Learning to use the same jargon as those who control resources is a basic skill used by people control resources is a basic skill used by people from grassroots to international levels to gain from grassroots to international levels to gain access to resources. access to resources.

However, problems begin when people begin to However, problems begin when people begin to use “OVC,” “CABA” (children affected by AIDS), use “OVC,” “CABA” (children affected by AIDS), or other terms to refer to actual children. The or other terms to refer to actual children. The result is stigmatization of the children intended result is stigmatization of the children intended to benefitto benefit (Williamson,

2008)


Global mobilization around AIDS-Global mobilization around AIDS-affected children important, but poses affected children important, but poses dilemmas concerning accuracy, equity dilemmas concerning accuracy, equity and stigmaand stigma

Policymakers, donors & programmers Policymakers, donors & programmers should avoid imposing specific eligibility should avoid imposing specific eligibility criteria as to which vulnerable children criteria as to which vulnerable children and households should be targeted for and households should be targeted for assistance.assistance.

Targeting ProgramsTargeting ProgramsA solution? A solution? Promote community involvement in decisions Promote community involvement in decisions

about who should receive program servicesabout who should receive program services Avoid explicitly targeting orphans or HIV-Avoid explicitly targeting orphans or HIV-

affected householdsaffected households Avoid using the label OVC to refer to children Avoid using the label OVC to refer to children

& discourage the community from doing so& discourage the community from doing so Target the most vulnerable by using a locally Target the most vulnerable by using a locally

appropriate combination of indicators, such as:appropriate combination of indicators, such as: Household poverty severityHousehold poverty severity Prime-age disabilityPrime-age disability High dependency ratiosHigh dependency ratios

Community identificationCommunity identificationAn example from the fieldAn example from the field

BeneficiaryBeneficiary n = 1023n = 1023 PercentPercent

Single orphanSingle orphan 650650 6464

Double Double orphansorphans

166166 1616

Ill guardian Ill guardian (includes single orphan)(includes single orphan)

108108 1111

Lives with Lives with both healthy both healthy parentsparents

102102 1010

One or more One or more parent absentparent absent

6161 66

(OVC TE Kenya Data, Kilifi, 2007)

1.1. Strengthen and support the capacity of families to Strengthen and support the capacity of families to protect and care for orphans and vulnerable children protect and care for orphans and vulnerable children

by prolonging the lives of parents and providing by prolonging the lives of parents and providing economic, psychosocial and other supporteconomic, psychosocial and other support

1.1. Strengthen and support the capacity of families to Strengthen and support the capacity of families to protect and care for orphans and vulnerable children protect and care for orphans and vulnerable children

by prolonging the lives of parents and providing by prolonging the lives of parents and providing economic, psychosocial and other supporteconomic, psychosocial and other support

2. 2. Mobilize and strengthen community-based responsesMobilize and strengthen community-based responses2. 2. Mobilize and strengthen community-based responsesMobilize and strengthen community-based responses

3. 3. Ensure access for orphans and vulnerable Ensure access for orphans and vulnerable children to essential services, including education, children to essential services, including education,

health care, birth registration, and othershealth care, birth registration, and others

3. 3. Ensure access for orphans and vulnerable Ensure access for orphans and vulnerable children to essential services, including education, children to essential services, including education,

health care, birth registration, and othershealth care, birth registration, and others

Strategies for InterventionStrategies for InterventionStrategies for InterventionStrategies for Intervention

(OVC Framework, 2007)

4. 4. Ensure that governments protect the most Ensure that governments protect the most vulnerable children through improved policy and vulnerable children through improved policy and

legislation and by channeling resources to families legislation and by channeling resources to families and communitiesand communities

4. 4. Ensure that governments protect the most Ensure that governments protect the most vulnerable children through improved policy and vulnerable children through improved policy and

legislation and by channeling resources to families legislation and by channeling resources to families and communitiesand communities

5. Raise awareness at all levels through advocacy and 5. Raise awareness at all levels through advocacy and social mobilization to create a supportive environment social mobilization to create a supportive environment

for children and families affected by HIV/AIDSfor children and families affected by HIV/AIDS

5. Raise awareness at all levels through advocacy and 5. Raise awareness at all levels through advocacy and social mobilization to create a supportive environment social mobilization to create a supportive environment

for children and families affected by HIV/AIDSfor children and families affected by HIV/AIDS

Strategies for InterventionStrategies for InterventionStrategies for InterventionStrategies for Intervention

(OVC Framework, 2007)

Service Delivery Service Delivery A Numbers gameA Numbers game

3 = 13 = 1 Primary Direct Support equals OVC who are Primary Direct Support equals OVC who are

counted as receiving PEPFAR funded or leveraged counted as receiving PEPFAR funded or leveraged support in support in three or morethree or more of the core dimensions of of the core dimensions of OVC servicesOVC services

Recognizes that most effective interventions Recognizes that most effective interventions are multi-sectoralare multi-sectoral

However, issues of Quantity vs Quality?However, issues of Quantity vs Quality?

Service DeliveryService Delivery

A Numbers gameA Numbers game

Double countingDouble counting Same child counted as served twice Same child counted as served twice

across and within organizations across and within organizations

Winterveldt HIV/AIDS Project Winterveldt HIV/AIDS Project South AfricaSouth Africa

Primary Direct OVC Support Males Females Total Clinical Nutrition Interventions 21 32 53 Food Parcels 21 26 47 Accommodation/housing interventions 13 22 35 Child Protection 71 49 120 Access - Health Facility 27 45 72 Access - ART 15 14 29 HIV/AIDS Prevention and Education 25 41 66 Emotional and Life Skill Support 29 21 50 Educational Access 19 16 35 Vocational Training 19 5 24 Income Generating Skills 6 12 18 Total 266 283 549

Winterveldt HIV/AIDS Project, Draft Case Study

“During the period between June 2006 -June 2007, the project directly serviced a total of 549 OVC.”

Service deliveryService delivery

What’s coming:What’s coming: OVC Databases with unique id #sOVC Databases with unique id #s Increased data quality assessmentsIncreased data quality assessments

But, still, there are issues with But, still, there are issues with verification….verification….

Do large programs even know?Do large programs even know?

An example from the fieldAn example from the field

Service Received Service Received (a sample from (a sample from 2 areas)2 areas)

PercentPercent

Child Level (n=617)Child Level (n=617)

School MaterialsSchool Materials 38.938.9

Vitamin AVitamin A 14.714.7

DewormingDeworming 38.738.7

BilharziaBilharzia 24.124.1

Household Level (n=471)Household Level (n=471)

Community Health Worker Community Health Worker 37.637.6

“All 20,000 children supported by our program receive

annual health vaccinations and home visits from a trained CHW”

OVC TE Kenya Evaluation Data, Kilifi

Service deliveryService deliveryConsiderationsConsiderations

Services given to child should also be Services given to child should also be made available to adult caregivermade available to adult caregiver Healthcare, psychosocial support Healthcare, psychosocial support Note: Key Recommendation for OVC care but Note: Key Recommendation for OVC care but

often won’t “count” as an OVC serviceoften won’t “count” as an OVC service

Serving the needs of ALL children in the Serving the needs of ALL children in the homehome

Sustainable services Sustainable services e.g., community gardense.g., community gardens

Graduation?Graduation?

Government protectionGovernment protection Institutions: Institutions:

NO! NO! NO!NO! NO! NO! Many children actually have a surviving Many children actually have a surviving

parent or extended kin who could care for parent or extended kin who could care for themthem

Potentially detrimental to child Potentially detrimental to child development and adult community development and adult community reintegration reintegration

ExpensiveExpensive ““From charity to profit making”From charity to profit making” Existing institutions needs regulations and Existing institutions needs regulations and

plans to reintegrate children plans to reintegrate children

Government protectionGovernment protection

Government support structures & Government support structures & social service opportunitiessocial service opportunities Social WorkersSocial Workers Access to social grants & cash transfersAccess to social grants & cash transfers Is the foster care system in the US Is the foster care system in the US

“sustainable?” “sustainable?”

Community-based CareCommunity-based Care

Avoid romanticizing the situationAvoid romanticizing the situation ““Traditional system of fostering”Traditional system of fostering” Urbanization, migration Urbanization, migration Increasing primacy of nuclear family Increasing primacy of nuclear family Recognize and address stigma in Recognize and address stigma in

interventionsinterventions OVC assumed or actual behavioral & OVC assumed or actual behavioral &

emotional problemsemotional problems Cause of parental deathCause of parental death PovertyPoverty NGO supportNGO support

Community-based CareCommunity-based Care

Community committeesCommunity committees Apply participatory approachesApply participatory approaches Don’t provide external resources to Don’t provide external resources to

community committees until they invest community committees until they invest internal resourcesinternal resources

Care for the volunteerCare for the volunteer Compassion burn-out Compassion burn-out Transference of burdenTransference of burden

(Williamson, 2008)

What What Works?Works?What What

Works?Works?

What works?What works?

Impression is that, until recently, donor & NGO Impression is that, until recently, donor & NGO emphasis has been on mounting an emphasis has been on mounting an urgenturgent rather rather than an than an effectiveeffective response response

From a scientific perspective, most evaluations of From a scientific perspective, most evaluations of OVC programmes have been poorly designed, OVC programmes have been poorly designed, conducted, reviewed and disseminatedconducted, reviewed and disseminated

Very substantial resources are now going into Very substantial resources are now going into OVC programsOVC programs

Need for scientific evidence concerning the Need for scientific evidence concerning the effectiveness of OVC programseffectiveness of OVC programs

(Gregson, NIH/USAID OVC Mtg, 2008)

Way ForwardWay Forward

Which interventions meet the needs of AIDS Which interventions meet the needs of AIDS affected children? (without causing further affected children? (without causing further stigma)stigma)

Which interventions are most effective at Which interventions are most effective at meeting the needs of both children affected by meeting the needs of both children affected by AIDS as well as the majority of highly AIDS as well as the majority of highly vulnerable children?vulnerable children?

How do we know it works? Need to: How do we know it works? Need to: Establish Criteria for success for various approachesEstablish Criteria for success for various approaches Ensure cost effectiveness.Ensure cost effectiveness. Ensure benefits are sustainableEnsure benefits are sustainable Apply rigorous investigation methodsApply rigorous investigation methods

A new term?A new term?

Highly Vulnerable Children (HVC)Highly Vulnerable Children (HVC)

Those children under 18 whose safety, wellbeing Those children under 18 whose safety, wellbeing or development is at significant risk due to or development is at significant risk due to inadequate care, protection or access to essential inadequate care, protection or access to essential services. Includes: services. Includes: Orphaned or those who receive inadequate adult Orphaned or those who receive inadequate adult

support because of death, abandonment, economic support because of death, abandonment, economic distress, or chronic illness distress, or chronic illness

have HIV/AIDS or are suspected of having hiv; have HIV/AIDS or are suspected of having hiv; are directly affected by armed conflict; are directly affected by armed conflict; live outside of family care; live outside of family care; or in some other way have suffered from a collapse or in some other way have suffered from a collapse

of traditional safety nets in their community. of traditional safety nets in their community.

(USAID first annual report to congress, Aug 2007 )(USAID first annual report to congress, Aug 2007 )

All for now….All for now….

Enjoy the Festival…Enjoy the Festival…

Orphans and Vulnerable Children in sub-Saharan Africa

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