Kenya + 4 more

Field Exchange May 2005: No. 25


From the Editor
This special issue of Field Exchange focuses on the food aid component of HIV related programming and was made possible through additional funding from DFID RSA. How the ENN have gathered field material for this issue marks a significant departure from our usual approach, in that a consultant (Mary Corbett) was taken on as a kind of roving researcher/correspondent. Mary visited five countries over the course of six weeks (Malawi, Zambia, Kenya and Uganda and South Africa) to meet with a wide variety of agency staff implementing HIV programming with a food aid component. Her brief was to describe these programmes and, where possible, identify lessons learnt. She was also asked to identify significant related research initiatives or findings in the countries visited. An account of the experience is captured in her editorial (page 17).

The rationale for this special issue was primarily that HIV-related programming involving food aid has been increasingly rolled out over the past few years, with a view to achieving a variety of objectives. Since much of this programming is 'cutting edge', many of the objectives have not been properly tested. Hence agencies are, effectively, learning by doing. The ENN (along with others) believes it important to document these new programming experiences to support a process of learning. Although the production of this special issue, based on 18 programme experiences, cannot be described as a comprehensive overview, it is, at least, a snap-shot of what is going on. The ENN believe that some of the lessons and cross-cutting issues to emerge from this special issue are important and indicate priorities and strategies for the future.

The agency field experiences documented are based on programmes implemented by a wide spectrum of agency types, i.e. UN, INGO, local NGO and CBO. Some of the CBOs literally started out as spontaneous community initiatives, led by a few dynamic individuals affected directly or indirectly by HIV. Over time, these organisations have professionalised, expanded, and achieved a significant profile and status with international agencies who now collaborate with them, and often provide resource support. The food aid and nutritional components of programming described here are integrated into several different programme types, i.e. DOT, HBC, CI/OVC, ARV, PMTCT and school feeding. Most of these programmes have multiple objectives for the food aid component. Furthermore, although the programme write-ups have focused on the food aid element of programming, many contain other sectoral elements as part of an overall integrated programme package. For example, the CRS programme in Dedza, Malawi (p38) not only targeted food aid to PLWHA households, but also contained an IGA element, as well as vocational training for older orphans.

There are a number of key findings from this snap-shot of agency programming:

Objectives and evidence of impact

Multiple objectives for the food aid element of programming are invoked. For example, the 18 month food aid package as part of the PMTCT programme at St. Gabriels Hospital in Malawi (by Gertrude Kara and Mary Corbett) is meant to encourage compliance and ongoing educational support, support abrupt weaning, ensure full infant immunisation, ensure VCT for infants on reaching 18 months and provide an opportunity to target IGA. The community school feeding programme in Zambia (by Kate Vorley and Mary Corbett) is aimed at improving enrolment in HIV affected areas and dissemination of HIV related knowledge. The food aid component of Oxfam's integrated programme in Malawi (p22) is intended to break the cycle leading to individual and household crisis. While food aid may, indeed, be able to serve a myriad of objectives within different programming contexts, it is notable that almost all objectives (which either appear in programme documents or are assumed by programme implementers) are expressed in general and qualitative terms, i.e. specific quantifiable targets are not set. Thus, where the objective is to increase weight gain or survival of HIV affected individuals, the actual percentage weight gain or percentage increase in survival hoped for is never explicitly stated. As a result, achievement of objectives cannot be tested. Indeed, in some cases and contexts, it may be unrealistic to set specific targets, especially where there is little prior programme experience. However, if targets remain nebulous, then progress in understanding whether and how food aid/nutritional support is effective cannot be made. In some contexts where there is adequate infrastructure and staff capacity, e.g. DOT and PMTCT, targets should be established as a priority, so that data can be rapidly generated to test the degree to which objectives are being met. Also, by establishing targets, it is more likely that implementing agencies will invest in collecting, collating and analysing data to demonstrate programme impact.

Findings from the ENN field work support the ubiquitous 'impression' that very little impact assessment is taking place. Most of the programmes visited had either not collected impact data, or had collected data but not undertaken analysis. In many cases this was attributed to lack of time and resources, with some agencies admitting the need for professional support (e.g. Reach Out programme in Uganda). While this is a credible excuse for CBOs and local NGOs, it is less understandable for INGOs or UN agencies. The absence of impact analysis is worrying and undoubtedly explains why there is currently very little in the published literature on this relatively new type of programming. The impact data that have been collected do appear to show some impact in terms of weight gain1. However, much of these data and analysis lack statistical rigor and are conceptually weak. This is not to be overly critical. Impact assessment of this type of programming is methodologically complex. For example, in a food aid/ARV or DOT programme, it would be necessary to isolate the impact of food aid in terms of improving tolerance to drugs, ensuring better and longer compliance with treatment, or reducing opportunistic infection by improving nutritional status. In the case of integrated food security programming, e.g. Oxfam and CRS programmes in Malawi, it would be necessary to control for a number of external factors like rainfall/climate, agricultural inputs and initial wealth status, in order to draw conclusions regarding the role of food aid in strengthening longer term food security. Generally, there has been insufficient attention given to impact assessment methodology for emergency related programming. Apart from the methodological challenges, there are also difficult ethical considerations in impact assessment. Given the large numbers of unknowns with respect to food aid and nutritional support in the context of HIV programming, there is an urgent need to strengthen the ability of implementing agencies (especially CBOs and local NGOs) to undertake impact assessment.

Anecdotally, IP staff and beneficiaries indicate enormous value of food aid as a component of the many types of HIV related programming. Benefits cited touch on many of the objectives claimed for these types of programming, e.g. weight gain, improved well-being, less mortality, improved programme compliance, longer-term food security. With the exception of longer-term food security, there is no reason to disbelieve these findings, especially when one considers that much of the targeting is to the poorest of the poor (see section on targeting). However, we have to do better than relying on anecdotal reports of programme benefits in order to strengthen understanding of how programmes are working (what is the process underpinning impact) so that programme design can be strengthened, and so as to increase belief in this type of programming - particularly in an environment where donors are increasingly sceptical of the benefits of food aid/HIV programming.



- WFP recipients' weight gain at Reach Out clinic

- Impact of HIV/AIDS on household food security and quality of life in Malawi

- Integrating CTC and HIV/AIDS Support in Malawi

- HIV and child mortality

- BMI: A Strong and Independent Predictor of Survival

- Rethinking food aid in the face of HIV/AIDS

- Early exclusive breastfeeding increases HIV survival

- Bangwe home based care project in Malawi

- Pregnant women's uptake of antiretroviral prophylaxis

- Modification of complementary foods in Zambia

- Better practice in targeted food assistance

- Cotrimoxazole as a prophylaxis for HIV positive malnourished children

- On-the ground perceptions of WFP food assistance and PMTCT in Zambia

ENN in the Field

- Editorial

- Impact of HIV/Aids on acute malnutrition in Malawi

- Integrated PMTCT services in a rural setting in Malawi

- Integrated approach to supporting chronically ill in Malawi

- School Feeding programme in Zambia

- REEP experiences in Western Kenya

- REACH OUT food assistance in Uganda

- Meeting Point: a local CBO in Uganda 31 News

- UN draft guidance on programming

- HIV/AIDS: A Guide for Nutritional Care and Support

- CRS conference in South Africa

- Invite to join WABA HIV and Infant Feeding Group

- New e-resources on HIV and AIDS

- Local resources for supporting PLWHA

- Fact sheets on ARV treatment for NGO/CBO staff

- Community based technology to combat HIV/AIDS


- South Africa HIV/Aids Pandemic

- Support for PLWHA'S in Malawi


Field Articles

- WFP HIV/AIDS programming in Malawi

- Emmanuel International

- HIV/AIDS and Food Security in Malawi

- Nutritional support through HBC in Malawi

- Three Ingredients of Success:Targeting Food Assistance in Western Kenya

- Participatory approach to food security in Uganda

- Evolution of GOAL activities in Malawi


- Targeting vulnerable households within the context of HIV/AIDS in Malawi

- WFP Monitoring and Evaluation of HIV/AIDS programming in Malawi

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