House of Commons - International Development

Select Committee on International Development Written Evidence

2. Memorandum submitted by Save the Children UK

1. Save the Children is the UK's leading international children's charity working in over 70 countries worldwide. In many countries, we are working directly with orphans and vulnerable children (OVC).

2. The global HIV/AIDS epidemic claimed more than 3 million lives in 2003. Over 75% of those deaths occurred in sub-Saharan Africa. Africa is experiencing an unprecedented crisis due to the loss of health and life from HIV/AIDS. One of the most tragic results of the HIV/AIDS pandemic is its impact on children. Although exact figures are unknown, it is predicted that by 2005 over 20% of all the children under age 15 in the sub-Saharan Africa will have lost either one or both parents, the majority from AIDS[74] Children are the most affected and the most marginalised in the fight against this epidemic. Significantly more investment is required that explicitly targets the prevention of new HIV/AIDS infections in children and young people, while providing appropriate care and support for children already affected.

3. Too often, donors and their funded programmes ignore the specific needs of children. This is fundamentally short-sighted. Children are central to the HIV/AIDS debate not only because of the current impact on rates of orphaning, but also because longer-term goals, such as the Millennium Development Goals, require long-term economic and human resource development. Meeting these goals depends on the current generation of children getting access to care and nurturing from loving adults, access to basic services, and a chance to reach their full intellectual, physical and emotional potential.

4. Children must lie at the centre of any HIV/AIDS response. Donors must encourage and support governments in their creation and implementation of national plans of action for OVC and ensure that comprehensive care, support and treatment includes children.

5. The lack of focus on OVC within the UK's Call for Action on HIV/AIDS is truly alarming. Interventions cannot occur in isolation. Governments must co-ordinate multi-sectoral responses to HIV/AIDS at top levels, ensuring the integration of community and state-led responses, only then can meaningful impacts be observed.

THE SITUATION FOR CHILDREN

6. Fourteen million children under age 15 have already been orphaned by HIV/AIDS, and this number is projected to double by the end of the decade. In the hardest hit countries of Southern Africa, up to one quarter of all children, one in eight of the entire population, is an orphan. In sub-Saharan Africa alone, there will be over 40 million orphans from AIDS and other causes by 2010.

7. There is no sign of HIV/AIDS prevalence rates peaking in the worst hit countries. Current adult HIV prevalence rates are as high as 33% in Zimbabwe, and over 38% in Swaziland and Botswana. AIDS-related morbidity and mortality are already reversing achievements made in child, family and community health[75]

8. Access to food and sustainable livelihoods are possibly the biggest challenges within Africa, especially for HIV-affected households and communities. Southern Africa is facing a chronic situation of food insecurity, exacerbated by and linked to HIV/AIDS. When someone in the household is sick, the family loses assets, savings and income; subsequently children (especially girls) are withdrawn from school. Recent research conducted by Save the Children in Swaziland[76] and Mozambique[77] indicates that disposable income in AIDS-affected communities is reduced by around 10%, while the additional costs to the household of taking in an orphan represent around 7% of household income in poorer households.

9. OVC also face reduced access to health care, reduced opportunities for schooling and education. Lack of access to these and other basic services will have long term implications on their overall development.

10. Children are increasingly vulnerable to a wide range of child protection abuses. One of the most common survival mechanisms that young girls resort to is transactional sex or very early marriage. Anecdotal evidence suggests that another common survival mechanism is theft by children in order to feed their family. Children in projects supported by Save the Children often complain about having too much work to do and getting married at a very early age to reduce economic pressure on the family.

11. Loss of access to entitlements such as land, property, and assets is a large and growing problem that requires practical interventions with communities, traditional leaders and law enforcement/welfare bodies. 70% of all children born in sub-Saharan Africa do not have birth certificates, causing profound implications for longer-term access to the facilities that citizenship should provide[78]

12. The visible social and economic impacts of AIDS on children often hide severe psychological consequences that the children experience. Psychosocial needs are frequently overlooked because many adults lack basic skills in recognising children's psychological or behavioural reactions. Patterns of psychological morbidity in children are starting to appear in families affected by HIV/AIDS. These include: showing signs of psychological disturbance, ie being unhappy, worried, lonely, or fearful of new situations[79]: showing depressive rather than anti-social behaviour, linked to a greater tendency to feel fatalistic and lacking control over their situation; being less positive and optimistic about the future[80]; lower self-esteem, appearing miserable, tearful, or distressed; truancy, and be more likely to migrate, even at a young age, in search of work[81]

13. Succession and inheritance planning for AIDS-affected households is an area in need of an urgent and widescale response. These are often termed "memory" approaches. Evidence suggests that inheritance planning may be more crucial in urban areas[82], but the need is widespread. In Rakai, Uganda, it has been shown that training of local government workers and community-based volunteers can greatly reduce the occurrence of property grabbing.[83] Practitioners typically do not know about appropriate accountability mechanisms, the relative merits of formal versus customary inheritance practices, and who the right arbitrators are in inheritance cases, beyond the catch-all subgroup of "community leaders".

14. Children are often cast in caregiving roles for their sick parents, elderly relatives and/or younger siblings. In 7% of a sample of AIDS-affected households in South Africa, a child was the primary caregiver for a sick adult[84] Children who are required to care for younger siblings or to engage in extra domestic chores complain of lack of time to play or to interact socially with peers. Over time, this leads to a restricted social circle and truncated relationships, which could prove crucial when the household experiences periods of extra stress and depends on outside assistance. In Malawi, orphans tend to form friendships with other orphans, which potentially could result in social stratification rooted in patterns of stigma and discrimination[85]

15. Where adults die and a child becomes the household head, the continuation of the household structure indicates its potential viability as a caring model. While not preferable as a care option, the prevalence of child-headed households is on the increase. In Zimbabwe, estimates suggest that 25,000 children currently live in such households, with this figure projected to rise to 100,000 by 2020.[86] In genocide-impacted Rwanda, not only is the occurrence of fostering far above average for an African country, but the number of children living in child-headed households is also extremely high; between 200,000-300,000 children in 2003[87] The child-headed household may indeed be viable if appropriate monitoring and support connections within the community are established. Semi-formal visitor programmes do exist; but beyond a handful of case studies, good practices are again lacking.

16. Policy makers should be aware that fostering could be appropriate even in cultures where it is deemed "untraditional." Conversely, fostering in situations where it is the norm does not necessarily mean that the arrangement is in the child's best interests. The appropriateness of informal fostering hinges on questions of parental motivation and the likelihood of permanency for the placement. Crucially, there are no tools to assist programme designers and project workers arbitrating in such decisions, potentially allowing continued abuses and exploitation to flourish in areas of high adult mortality.

SHAPING THE FUTURE RESPONSE

17. Terminology and labelling is important. The phrase "AIDS orphan" should not be encouraged, not least because it is then perceived that the child is an orphan who has AIDS which can be very stigmatising. More important are local definitions of orphanhood and vulnerability generally, which may include abandoned children (such as in Romania), children living in destitute households, those whose parents are sick, unemployed, or whose caregivers are elderly. Defining a child as an orphan may itself reinforce feelings of being different and impede integration into a foster family. In resource-poor, high HIV prevalence countries, the intuition to target orphans for assistance on the grounds that they are a priori more vulnerable than non-orphans is misguided.

18. Counting orphans accurately and defining their vulnerabilities compared to other children is problematic. The current orphan macro-definitions and estimates mask vulnerabilities apart from parental death. First, an unknown number of children are living with parents who are suffering from HIV-related illnesses, while many more are living with asymptomatic HIV-positive parents. Many children in sub-Saharan Africa live in households other than with their parents; as between 10-15% of all children are cared for by non-parent relatives. The loss of a foster parent can be as traumatic to such children as the loss of a parent, and many foster parents are dying due to AIDS. Their children can go unreported in models and enumerations.

19. One priority is to ensure that where HIV/AIDS money is available, it is reaching affected communities; for example, welfare systems strengthening in rural areas. Save the Children's successful Child Social Care project in Rakai district, Uganda proved the effectiveness of district level, decentralised orphan support structures, given the necessary political and financial commitment. Sustainability of such systems is dependent on ongoing commitment combined with a high degree of transparency and minimum standards of governance[88]

20. Strengthening government capacity is an overarching concern in heavily affected countries. In many African countries, "children's" and "social welfare" ministries are under-funded and have a great lack of capacity. In Lesotho, the children's sector is housed as a sub-section within the Ministry of Health. Consequently, although one in every eight people in Lesotho is an orphaned child under the age of 15, it has been hard to get children's issues on the agenda. "Children's" and "social welfare" ministries need greater support from within their governments, with a facilitated dialogue with the ministries of finance and planning. Some countries, such as Namibia, have made rapid and impressive strides towards child-focused budgets and policies. There needs to be more opportunity for such countries to exchange experiences, and more pressure from the international community to support a rapid introduction of national strategic planning for orphans and other children made vulnerable by HIV/AIDS.

21. Global financial mobilisation for AIDS-affected children has been disappointing. Save the Children has reviewed the Global AIDS TB and Malaria Fund allocations and has found that only 21% of proposals mentioned orphans and vulnerable children as a target group and less than 3% of monies in successful proposals were allocated to orphans and vulnerable children[89] One way to combat this it to involve these affected groups more in the proposal process. By involving those representing children and young people's views and needs with the country coordination mechanisms (CCMs), children will remain at the top of the HIV/AIDS agenda.

22. Access to education is critical to the social and intellectual development of children. In developing effective responses, it is essential to consider the reasons why children do not attend school. While lack of school fees is often cited as a reason, even in countries where primary education is free (Malawi and Lesotho, for example) many children do not attend because of other tasks such as domestic, piece or agricultural work. Save the Children is involved with some small-scale interventions, such as "crop sharing" in Lesotho. This supports communities to provide enough food and additional adult support to keep children in school. Efforts addressing the breadth of reasons that children are not in school are more effective than vertical interventions.

23. Focusing on the means of consulting children is one example of how to ensure greater responsiveness to children's needs. Children's involvement in programme design and implementation further cultivates the abilities of these children establishing them as the leaders of tomorrow. In Zimbabwe, Save the Children has established a child advisory board to improve the quality of their programmes. This allows for continuous feedback throughout the programmes, allowing children to input into all aspects of programme development. The work takes time but is worth the investment, as acceptance, relevance and sustainability are more assured.

24. There are currently over 8 million children living in residential care worldwide. The reasons for this are multiple and complex, and are increasingly exacerbated by poverty, migration, HIV/AIDS and armed conflict. Based on extensive documentation and first-hand experience, Save the Children concludes that residential care as a long-term environment for children is associated with increased risk to children both during care and following it. Save the Children believes that children's homes provide a variable quality of care. Children's rights may be ignored or directly abused and this has significant effects on their quality of life. Institutional care facilities are opening in areas of high HIV/AIDS prevalence, encouraged by the lack of an overarching policy framework, fuelled by external and often misguided financial assistance.

25. The recent announcement of the World Health Organisation's "3 by 5" strategy offers great opportunity to strengthen health systems to increase the ability to successfully deliver care, support and treatment to affected families. Already half of the financial allocations are for drugs and commodities, with only 15% reserved for infrastructure development. "3 by 5" will place even greater pressure on already overstretched health systems. Health systems development should be part of all widescale ARV distribution programmes. Keeping mothers alive longer, an aim of the 3 by 5 strategy, would mean more families staying together longer and the prevention of orphaning itself.[90]

CONCLUSION: A GLOBAL RESPONSE

26. The UK must lead by example. OVC must become a priority focus for policy as well as resources within the UK's Call for Action on HIV/AIDS. DFID has endorsed the UN Global Strategic Framework for the Protection, Care and Support of Orphans and Other Children Made Vulnerable by HIV/AIDS and therefore should make specific OVC policy commitments in the HIV/AIDS Strategy to support the implementation of this Framework. A leading role would entail the UK working with other G8 and EU partners to ensure the implementation of this global Framework.

27. The UK must support countries to include OVC in their applications to the Global Fund to fight AIDS, TB and Malaria. The Global Fund represents an excellent means of increasing funding and one way of ensuring that proposals include children is by encouraging child participation at the country level within the CCM support mechanisms. DFID is a member of around half of the CCMs, and has crucial role to play in ensuring that OVC are not forgotten in country applications.

28. Most countries have signed up to the UN Declaration of Commitment on HIV/AIDS (2001) clearly stating national obligations around OVC[91] In spite of this, progress in planning and implementing such strategies has been painfully slow. Over 40% of countries with generalised HIV epidemics do not yet have a national OVC strategy. Countries need to be called upon to create and implement such plans and supported to ensure that they do so in a way that can be monitored over the long term.

29. The UK must use its influence in the World Bank and other international fora to secure the abolition of education and health charges for orphans and children affected by HIV/AIDS.

30. The UK must prioritise the sustainable development of health systems as a prerequisite of achieving the "3 by 5" initiative and MDG targets.

31. The UK must back programmes that direct resources to building communities' capacity to care for children. These interventions need to focus on keeping children in communities. Institutional care must be seen as the option of last resort.

March 2004

74 Children on the Brink 2002, USAID/UNICEF/UNAIDS, July 2002. Back

75 No Quick Fix: A sustained response to HIV/AIDS and children, Save the Children UK. Back

76 Save the Children UK and Save the Children Swaziland, HIV/AIDS and household economy in a Highveld Swaziland community, London, draft, 2004. Back

77 Mozambique assessment: the Impact of HIV/AIDS on Household Economy, Food Security and Livelihoods Unit, Save the Children UK, draft, 2004. Back

78 Peter Stalker, July 2003, "Africa's orphan generation", draft paper for USAID. Back

79 Poulter, C 1997. A psychological and physical needs profile of families living with HIV/AIDS in Lusaka. Family Health Trust/UNICEF, Lusaka. Back

80 Sengendo, J and J Nambi. 1997. The psychological effect of orphanhood: A study of orphans in Rakai district. Health Transition Review, Supplement to Vol 7:105-124. Back

81 Ledward, A 1997. Age, gender and sexual coercion: Their role in creating pathways of vulnerability to HIV infection. Masters dissertation, University College, London. Back

82 Magalla, A, H Houlihan, D Charwe et al 2002. Urban-rural differences in programs on orphans and vulnerable children in AIDS affected areas in Tanzania. Paper presented to the XIV International Conference on AIDS, Barcelona. Back

83 Save the Children UK (2004) Taking Better Care? Review of a decade of work with orphans and vulnerable children in Rakai, Uganda, London. Back

84 Reported in Mail and Guardian, Johannesburg, 27 September 2002. Back