BACKGROUND
The Consortium for the Southern Africa Food Security Emergency (C-SAFE) is currently implementing the final year of a three-year 'developmental relief' program. C-SAFE's strategic objectives include: 1) to improve/maintain nutritional status; 2) to protect productive assets; and 3) to support households and communities to strengthen their resilience to current and future food security shocks that affect their wellbeing and livelihoods1. C-SAFE's Learning Spaces initiative provides a vehicle for learning among consortium members and other stakeholders on key themes such as HIV/AIDS and food security, food aid targeting, nutrition and supplementary feeding, the concept of developmental relief, and lessons learned from working in a consortium format.
Over the past two years, C-SAFE has struggled to find effective and appropriate indicators for measuring the effect of food assistance on chronically ill beneficiaries. C-SAFE has experimented with the use of food security and livelihood indicators in lieu of nutrition indicators, and has included indicators such as 'eating more types of food'; eating more often; HH spends less money on staple food; ill members are able to return to work; caretakers of ill members are able to work; orphans can go to school instead of work and/or beg' in the Post Distribution Monitoring tool in Zambia. In Malawi, C-SAFE has used focus groups to gauge the effect of food on chronically ill individuals and households affected by chronic illness, relying again mostly on food security and livelihood indicators to measure progress. However, there has been a growing awareness of the challenges inherent in measuring the effect of food on the primary beneficiary (the 'patient'), especially in the context of a household ration or where a nutrient-dense commodity (such as Corn Soy Blend [CSB]) cannot be provided.
Several of C-SAFE's members have recently engaged in linking targeted food assistance to medical interventions such as TB-DOTS2 and Antiretroviral Therapy (ART). While it has been a relatively straightforward task to target individuals engaged in these two forms of treatment, it is not clear how well C-SAFE is monitoring their progress or to what extent C-SAFE should make use of existing mechanisms (i.e. clinic staff/records) for that purpose. The clients are being weighed regularly, and a range of indicators are being used by clinic staff to assess progress, but C-SAFE staff have not, in general, taken advantage of this information, nor have we systematically applied other (livelihoods or nutrition) indicators. The most common measure of 'success' has been attached to program adherence, as indicated by checking the individual's treatment card and verifying adherence with the treatment supporter.
To assist Consortium members to begin to 'unpack' this complex issue, a study was commissioned by C-SAFE Learning Spaces in November 2004. This paper presents findings of a review of the literature conducted in December 2004, aimed at identifying current knowledge and practices of assessing the effect of Targeted Food Assistance (TFA) on people living with HIV/AIDS (PLHA). Field interviews were subsequently conducted in February 2005 in Malawi, Zimbabwe and Zambia to complement the review. Recommendations for monitoring and evaluating TFA are provided based on the literature review and preliminary analysis from the fieldwork. The focus of this study was on four particular sub-groups of PLHA. These are: 1) Chronically Ill (CI), which is used by C-SAFE and WFP as a proxy for symptomatic PLHA (i.e. people with AIDS); 2) women engaged in PMTCT programs; 3) PLHA on ART; and 4) PLHA on TB treatment.
The term Targeted Food Assistance (TFA) can be interpreted in many ways, to include individual or household rations, dry or wet distribution methods, and includes/overlaps with 'supplemental' and 'complementary' feeding. For the purposes of this paper, 'TFA' is used to refer to any kind of food aid delivered to a targeted population.
OBJECTIVE
Although there is a growing body of knowledge on the link between nutrition and HIV disease progression, little is known about the effect of TFA on PLHA. Food aid targeted at a variety of population groups such as children, the chronically ill, and people on TB-DOTS or ART has, generally, been based on need, although 'need' has been defined by many different stakeholders and in many different ways.
The objective of this research was to investigate current practices for measuring effect of TFA on PLHAs through a review of the literature followed by interviews and observational visits of PLHA food aid programs in Malawi, Zimbabwe and Zambia.
METHODOLOGY
The literature review included a search of PUBMED, AEGIS, the Cochrane Database of Systematic Reviews and the search engines of major food relief and development agencies. Agencies reviewed included The World Bank, FAO, IFAD, World Food Program (WFP), FANTA, USAID, AED, Save the Children and IFPRI. The following key word combinations were used in combination with HIV/AIDS: Food and medicine Food relief Food supply Hunger and medicine Medical and interventions and food and relief Nutrition and medicine Nutrition and surveys and medicine
Searches were further refined through the screening of reference lists for relevant papers. When saturation of the literature was achieved, each paper was scrutinized for information on nutritional status and the effect of TFA in the context of HIV/AIDS. Since the literature is limited in this area, a wider review of literature was then done, including disease progression and nutrition, effect of treatment, and psychosocial issues.
In the field, information was gathered from a review of the literature, key informant interviews, group discussions, observational visits and collection of current monitoring and evaluation tools. In each study country, a local representative identified appropriate field sites to visit and stakeholders to interview. During the visit, the researchers pursued some additional interviews and site visits as time allowed. A total of 66 individuals from 29 different agencies were interviewed across the three countries.
Footnotes:
1 The Consortium is operational in Lesotho, Zambia and Zimbabwe, and consists of three core NGO members, (CARE, Catholic Relief Services (CRS) and World Vision) with an additional member (ADRA) in Zambia. C-SAFE is a three-year program and was also active in Malawi for its first two years (FY03-04) of operations. For this reason, Malawi was covered in this study. C-SAFE Malawi has since transitioned to a Developmental Assistance Program (DAP).
2 TB-DOTS refers to Directly Observed Treatment, Short-course, for Tuberculosis
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