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HIV/AIDS Orphans and Vulnerable Children On-line
Toolkit: draft introductory texts
Contents
2.2 Doing the Work........................................................
...3
2.2.1 Local Advocacy.................................................
...5
2.2.2 Working with Volunteers...................................
...7
2.2.3 Running an Organisation..................................
...9
2.3 Improving the Work.................... .............................
.10
2.3.1 Monitoring and Evaluation................................
.11
2.3.2 Setting Standards..............................................
. 15
2.3.3 Working with Others..........................................
.17
3. Health and Nutrition...................................
.18
3.1. All Children......................................................
.21
3.1.1 Nutrition and Access to Food..........................
.22
3.1.2 Access to Health Care......................................
.24
3.2 Children Living with HIV/AIDS................................. .26
3.2.1 Access to Treatment.........................................
.30
3.2.2 Which Drugs?....................................................
.33
3.2.3 Practical Treatment Tips...................................
.38
4 Education........................................................................
42
4.1 Early Childhood Development.................................
44
4.2 School Age Children.......................... .....................
45
4.2.1 Access to Education.........................................
46
4.2.2 HIV/AIDS Awareness and Life Skills................
49
4.2.3 Strengthening Roles of Schools.......................
52
5 Psychosocial Support......................................................
53
5.1 Psychosocial Effects of HIV/AIDS...........................
54
5.1.1 Grief and Bereavement.....................................
56
5.1.2 Resiliency...........................................................
57
5.2 Psychosocial Responses..........................................
60
5.2.1 Counselling.........................................................
61
5.2.2 Succession Planning.........................................
63
5.2.3 Training in Psychosocial Support.....................
66
5.2.4 Examples of Psychosocial Responses.............
67
6 Economic Strengthening.................................................
68
6.1 Economic Responses...............................................
70
6.1.1 Skills and Vocational Training.................... ......
72
6.1.2 Financial Services for the Very Poor................
74
6.1.3 Agriculture..........................................................
78
6.1.4 Examples of Economic Strengthening Projects
80
6.2 Problems of Economic Responses.........................
81
6.2.1 Child Labour.......................................................
82
6.2.2 Economic and Sexual Exploitation of Children.
86
i
87
r
7 Living Environments........................................................................
89
7.1 Carers
92
7.1.1 Older Carers.......................................................................
93
7.1.2 Child-Headed Households.................................................
96
7.2 Children Living Outside of Family Care...................................
97
7.2.1 Commercial Farms and Other Workplaces......................
100
7.2.2 Prisons and Detention Centres..........................................
101
7.2.3 The Street............................................................................
104
7.2.4 Situations of Conflict...................................... ....................
106
7.3 Alternates to Community Care in Extended Families.............
108
7.3.1 Placement of a Child with Another Family........................
109
7.3.3 Residential Care.................................................................
113
8. Children’s Rights.............................................................................
115
8.1 Participation...............................................................................
118
8.2 Stigma and Discrimination.............................................
121
8.3 Protection from Abuse, Exploitation, Neglect and Trafficking
123
8.4 Legal Support............................................................................
124
8.4.1 Birth Registration...............................................................
125
8.4.2 Inheritance.........................................................................
2
2.2 Doing the Work
This section provides practical tips for organizations carrying out activities aimed
at providing support to orphans and other vulnerable children. It focuses
particularly on the type of activities which might form part of a community-based,
‘orphan’ visiting programme.
Other sections look at related issues, such as how such programmes might get
started (Hyperlink Section: ‘Getting Started') or be improved (Hyperlink Section:
Improving the Work ). Others examine specific issues related to doing the work
in more detail, for example local advocacy (Hyperlink Subsection: Local
Advocacy ), working with volunteers (Hyperlink Subsection: ‘Working with
Volunteers’) and running an organization (Hyperlink Subsection: ‘Running an
Organization’).
Key points about doing the work are:
1. Activities are most effective when they are carried out by individuals or
groups who are part of the local community. External organizations, such
as NGOs, need to play a facilitating role only.
2. Volunteers drawn from the local community constitute the most important
human resource in such programmes. Training, supporting and
motivating this group of people is animportant part of any programme.
(Hyperlink Subsection: ‘Working with Volunteers’).
3. Projects will need to have a way of keeping records which helps monitor
activities of the programme as a whole and the situation of individual
children (Hyperlink Subsection: ‘Monitoring and Evaluation’).
4. In situations of poverty, material support may be required by particular
children. However, there are many risks involved with this. Experience
has shown that material support is best provided through community
groups once they have demonstrated that they are able to prioritise
children in greatest needs and monitor activities, including the provision of
material support.
Visiting Orphans and Vulnerable Children
Many of the projects (Hyperlink Subsection: ‘Project Case Studies’) which work
with orphans and vulnerable children have some kind of visiting programme at
their core. These usually work through a group of volunteers/mentors
(Hyperlink Subsection: ‘Working with Volunteers’) who are selected from local
community members. These volunteers carry out a range of activities, which
may include:
»
»
Practical tasks, such as cleaning, washing, collection of firewood.
Counselling’ (Hyperlink Subsection. ‘Counselling ) - on issues including
.
.
bereavement and growing up
Teaching of skills, for example in home management
Psychosocial Support (Hyperlink Heading: ‘Psychosocial Support),
including showing love, spiritual support and teaching about culture and
Assessment of health and nutritional status (Hyperlink Heading. Health
and Nutrition ), including checking on immunizations, health card and
.
•
•
•
accompanying to clinic when ill
Ensuring that children attend school (Hyperlink Section: 'School Age
Children’) and that barriers to this are overcome
Providing support to caregivers (Hyperlink Section: Carers)
Prevention and detection of abuse (Hyperlink Section. 'Protection from abuse
etc.’)
Some organizations have developed frameworks for volunteers to operate within.
One of these is referred to as LEPO. It involves listening, encouraging, problemsolving and identifying other resources.
Some organizations conduct activities in addition to visiting orphans and
vulnerable children. In some situations, these activities are not linked to visiting
orphans and vulnerable children. These activities include:
•
•
•
•
Economic strengthening (Hyperlink Heading: Economic Strengthening )
Psychosocial support (Hyperlink Heading: Psychosocial Support)
Local advocacy (Hyperlink Subsection: Local Advocacy)
Protection from abuse (Hyperlink Section: ‘Protection from abuse etc.)
4
2.2.1 Local Advocacy
This section explores practical ways in which NGOs and CBOs might get
involved in advocating for children, particularly at local level. It also looks at the
issue of advocacy more broadly and briefly considers ways in which locallyfocused NGOs and CBOs can get involved in advocacy at national and
international levels.
Other sections looking at related issues include doing the work (Hyperlink
Section: Doing the Work’), working with volunteers (Hyperlink Subsection:
Working with Volunteers’) and running an organization (Hyperlink Subsection:
‘Running an Organization’).
Key points about local advocacy are:
1. Advocacy can be defined as pleading in support of others or speaking for
those who are powerless to speak for themselves.
2. The Convention on the Rights of the Child provides a powerful basis for
advocacy efforts at all levels (Hyperlink Heading: 'Children’s Rights’).
3. Many NGOs/CBOs find ‘advocacy’ difficult. However, local advocacy can be
started in a number of small practical ways, which are often simply an
extension of existing activities.
4. Locally-based NGOs/CBOs can often engage most effectively with advocacy
issues at national/international levels through involvement with networks and
coalitions.
What is Local Advocacy?
Advocacy has been defined as pleading in support of others or speaking for
those who are powerless to speak for themselves. Advocacy for orphans and
vulnerable children at local level might take a number of forms including:
•
Providing training about the rights of children (Hyperlink Heading:
‘Children’s Rights’), in general and the Convention on the Rights of the Child,
in particular. This training might be provided to community-based volunteers
working with orphans and vulnerable children and the children themselves.
•
Being aware of and focusing on children at particular risk.
•
Being careful to avoid terms (Hyperlink Section: ‘Terminology’) which
reinforce stigma (Hyperlink Section: ‘Stigma and Discrimination’), such as
AIDS orphans.
5
•
Using the law to protect the rights of children, for example on inheritance
(Hyperlink Subsection. Inheritance) of property.
•
Assisting children to get important documents, such as birth certificates
(Hyperlink Subsection: Birth Registration ).
•
Representing children’s interests in a variety of ways, including to social
workers, the police, courts, community leaders and to schools.
•
Assisting in a variety of ways to ensure that children gain access to important
services, such as health (Hyperlink Subsection: Access to Health Care’) and
education (Hyperlink Subsection: Access to Education ).
•
Using the media to disseminate information.
•
Linking to networks to participate in national and international advocacy.
6
2.2.2 Working with Volunteers
This section explores issues relating to ways in which NGOs and CBOs work
with community-based volunteers. Such people are often the key group in doing
work (Hyperlink Section: Doing the Work’) with orphans and vulnerable children
at community level. It looks at how these people are selected, trained and
supported.
Other sections looking at related issues include doing the work (Hyperlink
Section: ‘Doing the Work’), local advocacy (Hyperlink Subsection: ‘Local
Advocacy ) and running an organization (Hyperlink Subsection: ‘Running an
Organization’).
Key points about working with community volunteers are:
1. These volunteers should be selected by members of the local community
using a process and criteria agreed by the community.
2. Training should be relevant to the activities the volunteer is expected to carry
out and should be ongoing.
3. Ways need to be found to provide ongoing support and encouragement for
community-based volunteers. Initial training only is unlikely to be sufficient to
achieve this. Clear policies on ‘incentives’ for volunteers may need to be
developed.
4. In many projects, volunteers are mainly women. Ways need to be found to
mobilize men into these roles and to share the burden of care more equitably.
Visiting Orphans and Vulnerable Children
Many NGOs that work with orphans and vulnerable children do so by supporting
visiting programmes (Hyperlink Section: ‘Doing the Work’) which operate
through community-based volunteers. To get these programmes started
(Hyperlink Section: Getting Started’), such volunteers need to be selected. This
should be done by the local community using a process and criteria developed
by them. Examples of criteria for volunteers developed by one programme
include leading from the heart, people skills, ability to manage community
change, ability to be a role model and a sense of humour.
Training Volunteers
Many programmes conduct initial training for their community-based volunteers.
The precise content of this training varies but is likely to include training for what
the volunteer may need to do during a visit, sources of additional support and
7
record-keeping systems. Experience has shown that initial training alone is
unlikely to be sufficient, and that training needs to be ongoing.
Ongoing Support to Volunteers
A key element of working with volunteers involves supporting them in their work
on an ongoing basis. This support may take many forms and may include:
•
•
•
•
•
•
•
•
•
Ongoing training - this may include workshops, training elements in support
meetings and also exchange visits to other programmes
Support/supervision meetings
Feedback on individual and programme performance. This feedback may
come from various sources, including from inside and outside the local
community
Visits to the programme. These may be motivational, in that they give
recognition to the volunteers and the work they are doing. However, they can
be problematic particularly if the number of visits becomes excessive
Counselling and other supports to overcome problems of stress and burnout
Allowing volunteers to actively participate in programme development
Ensuring realistic workload, given that volunteers carry out programme
activities as volunteers, in addition to other responsibilities
Group identity - many volunteers gain support from religious bodies they
belong to
Material incentives - such as food, soap, T-shirts, shoes etc. This element is
potentially problematic because of the risk of creating dependency. Clear
guidelines may be helpful in this regard.
In many programmes, the majority of volunteers visiting orphans and vulnerable
children are women. This emphasizes the point that the burden of care which
results from HIV/AIDS is falling mainly on women.
8
2.2.3 Running an Organisation
In many cases community-based activities with orphans and vulnerable children
have not been started by an established organization but by an informal
community group or perhaps a church. In those cases, the people involved need
to learn a variety of skills, not only those specific to working with orphans and
vulnerable children, but also more general skills related to running a project, and
setting up an organization. Although this section contains some resources which
refer to these issues, many more resources are available in the International
HIV/AIDS Alliance’s NGQ/CBQ Support Toolkit (Hyperlink Toolkit).
Other sections looking at related issues include doing the work (Hyperlink
Section: ‘Doing the Work’), local advocacy (Hyperlink Subsection: ‘Local
Advocacy’) and working with volunteers (Hyperlink Subsection: ‘Working with
Volunteers’).
9
2.3 Improving the Work
This section looks at ways in which activities being carried out with orphans and
vulnerable children can be improved and strengthened. This is an essential part
of running a programme (Hyperlink Heading: Running a Programme) once it
has been started (Hyperlink Section: 'Getting Started) and some work is
already being done (Hyperlink Subsection: ‘Doing the Work’). Three essentia
elements are considered here, namely monitoring and
(^r"nk
Subsection: 'Monitoring and Evaluation'), work.ng with ?th^g (Hyperlmk
Subsection: ‘Working with Others’) and setting standards (Hyperlink
Subsection: ‘Setting Standards').
Key points about improving the work are:
Monitoring and evaluation (Hyperlink Subsection: ‘Monitoring and
1. Evaluation^) of a project helps establish what has been achieved, including
what has worked well and what could be better. Learning from such
activities can be valuable in improving work.
NGOs can work with others (Hyperlink Subsection: Doing the Work) in
2. a variety of ways, including through formal and informal networks and w th
implementing joint projects. This contact with other organizations local y,
nationally and internationally can be a useful way of learning about other
approaches which can be used to improve activities.
3. Setting standards (Hyperlink Subsection: Setting
reached in the provision of care for children can be useful for monitoring
and evaluation (Hyperlink Subsection: ‘Monitoring and Evaluation )
purposes, and for comparing different projects and approaches^ Sue
standards can be used by organizations as targets to aim for. This is
likely to improve the quality of work being carried out.
10
2.3.1 Monitoring and Evaluation
This section looks at the monitoring and evaluation of programmes. This is an
essential part of improving work (Hyperlink Section: ‘Improving the Work1).
Related sections include working with others (Hyperlink Subsection: ‘Working
with Others’) and setting standards (Hyperlink Subsection: ‘Setting Standards’).
Key points about monitoring and evaluation are:
1. Both monitoring and evaluation are processes used to assess project
progress.
2. ‘Monitoring’ refers to an ongoing system used to keep the project ‘on
track’.
3. ‘Evaluation’ refers to a one-off event conducted to account for resources
used and/or to document lessons learned.
4. There are two main approaches to evaluations. Scientific approaches
emphasise the importance of objective facts/evidence. Interpretive
approaches emphasis the views and perspectives of people affected
by/involved with the project. These people are termed ‘stakeholders’.
5. Many approaches to evaluation now'emphasise the active participation of
stakeholders, particularly children and young people. Different
stakeholders may have very different levels of power within a project.
6. Indicators are things which are used to measure or assess progress made
by a project. They may be expressed as numbers (quantitative) or
descriptive words (qualitative). They may be internationally or locallydefined and can be used to measure project activities at different levels,
for example processes/activities and outcomes/impacts
7. Good monitoring systems and evaluation approaches collect and compare
information from a variety of different sources using different methods.
This is termed triangulation.
Defining Monitoring and Evaluation
Resources in this section contain a number of definitions of the terms ‘monitoring’
and ‘evaluation’. These two processes both seek to examine and analyse the
progress of a particular project. They differ from each other in three main ways:
ll
1. Nature: The term monitoring is used to describe a system of collecting
and analyzing information about the work of the project. On the other
hand, the term evaluation is usually used to describe a specific event.
2. Timing: Monitoring is a regular and ongoing process which takes place
throughout the life of a project. An evaluation usually occurs at a
particular time, for example midway through a project or at the end.
3. Purpose: The purpose of monitoring is relatively narrow, in that it usually
focuses on keeping a project ‘on track’. This involves measuring what the
project has done and comparing this with its plans. Evaluation may have
broader purposes, for example assessing what has been learned as a
result of project activities.
Purpose of Evaluation
Two main purposes can be identified for conducting an evaluation. First, an
evaluation can be conducted to hold a project accountable for what it has done
and achieved. In such cases, actual project activities and achievements will be
compared with what was planned. Such evaluations are often required by donor
organizations that provide funds for a project. The receipt of further funds may
depend on achieving a satisfactory outcome to such an evaluation. Secondly, an
evaluation may seek to learn lessons from project activities. This is likely to
include an assessment of what worked well and what didn’t. Things that have
worked well may be referred to as ‘good’, ‘effective’ or ‘best’ practice. There is a
tension between these two purposes. For example, this may explain the reason
why ‘negative’ findings, that is what didn’t work, are rarely recorded in evaluation
reports. Although such findings are very useful for the purpose of learning, they
are problematic in terms of accountability, because donors are unlikely to be
willing to fund activities shown to be ineffective. Consequently, organizations
may not wish to publicise findings of this nature.
Ways of Conducting Evaluations.
There are a variety of ways of conducting evaluations. These can be divided into
two main types. The ‘scientific’ approach seeks to compare a group of people
receiving a particular intervention or service with a comparable group who do not
receive it. The purest form of this is referred to as a randomized, controlled trial.
It places strong emphasis on objective facts/evidence. On the other hand, the
‘interpretive’ approach places much greater emphasis on trying to understand the
views and perspectives of different individuals and groups associated with the
project.
Stakeholders
12
People associated with the project can be referred to as ‘stakeholders’. Many
different stakeholder groups can be identified for a particular project, including
the children and young people who are intended to benefit from it. These
stakeholders may have very different expectations of a project evaluation. Two
key issues relating to stakeholders and evaluation are:
1
Power: There may be power imbalances between different groups of
stakeholders. For example, donor views may be given greater weight
within an evaluation because they control project funds.
2. Participation: Interpretive approaches to evaluation place great emphasis
on the active participation of project stakeholders, particularly children and
young people, in an evaluation.
Indicators
Indicators are widely used in both monitoring and evaluation. Essentially, they
are things which can be measured or assessed to see the progress being made
by a project. They may be expressed in numbers (quantitative) or through
descriptive words (qualitative). They may form part of an international set of core
indicators or may be developed locally for a specific project. They may measure
different ‘levels’ of a project. These levels include:
•
Inputs - that is the things needed for the project to occur. An example of an
indicator of project inputs is project cost*
•
Processes - that is the activities of a project. In general, these are relatively
easy to measure and process indicators often form the bulk of monitoring
systems. An example of a process indicator would be the number of orphans
and vulnerable children visited by volunteers. In some situations, these
figures are expressed as the percentage of people who need a service who
actually receive it. This is termed ‘coverage’.
•
Outputs - that is things produced by the project, for example an upgraded
health facility.
•
Impact/Outcome - these are longer-term changes produced as a result of
the project. In many cases, it may be difficult to show clearly that these
changes have occurred as a result of the project because they are affected by
many other things. An example of an impact indicator might be children’s
nutritional status.
Some examples of process and outcome indicators used by programmes
working with orphans and vulnerable children are presented in the table below.
Process Indicators
Outcome Indicators
13
| Number of children assisted by the
programme
Number of community-based
volunteers (Hyperlink Subsection:
Working with Volunteers') within a
programme
Production of community-generated
financial and material resources
(Hyperlink Heading: ‘Economic
Strengthening’)
Number of volunteer training sessions
Number of supervisory visits carried
out by senior staff
Prevalence of abandoned
children/street children (Hyperlink
Subsection: The Street )/child-headed
households (Hyperlink Subsection.
‘Child-headed Households’)
Stunting and wasting
Dietary intake profile
School enrolment/drop-out
Immunisation status
Proportion of sibling separation
Primary carer income
Household land cultivation
Monitoring and Evaluation Methods
a
Monitoring and evaluation may use a variety or different methods for collecting
information. Primary methods are those used by the people doing the
monitoring/evaluation. Primary methods may include questionnaires, surveys,
focuse group discussions, direct observation and interviews with key informants
Secondary methods involve looking at work done by other people, usually
through reviewing project and other documents. Good quality monitoring and
evaluation uses information from a variety of different sources, collected using
different methods to cross-check its validity. This is called triangulation.
14
2.3.2 Setting Standards
This section looks at setting standards for activities which seek to provide care
and support for orphans and vulnerable children. It is part of improving work
(Hyperlink Section: 'Improving the Work ). Related sections include working
with others (Hyperlink Subsection: ‘Working with Others’) and monitoring and
evaluation (Hyperlink Subsection: 'Monitoring and Evaluation ).
Key points about setting standards are:
1. Standards can be used by an individual project/programme to assess their
own achievements and to have something to aim for
2. Standards can be used to compare different approaches. This may be
particularly important when trying to assess costs.
3. Standards can be set in a number of areas where children have needs/rights.
These include survival, security, socialization and self-actualisation.
Why are Standards Needed?
Organizations have very varied ways of working with orphans and other
vulnerable children. It may be extremely difficult to assess the relative
effectiveness of these approaches unless there are agreed standards for the kind
of care that needs to be provided. Such standards may be useful for individual
projects who can use them to assess how they are doing and as targets for
improved activities in the future. Also, such standards can allow comparisons to
be made between different project approaches. However, many of the standards
are affected by poverty in general. It may be necessary for communities to adapt
these standards so that they are appropriate for local settings.
Areas in which Standards are Useful
One approach is to identify four areas in which standards are needed. These
are:
1. Survival: This area covers a number of basic physical needs that children
have in order to survive. These include food, clothing, home environment,
hygiene/infection control, treatment and health care. It is possible to set
standards in each of these areas. For example, in South Africa under
‘food’, two standards were adopted, namely that children should receive
three meals per day and should be involved in food preparation and
choice.
15
2. Security: This area covers a child’s need for both protection and affection.
Areas in which children need protection include from abuse (Hypenink
Section: Protection from abuse.. ), stigma and discrimination
(Hyperlink Section: Stigma and Discrimination ) and from loss of parental
assets (Hyperlink Subsection: ‘Inheritance’).
3. Socialisation: This covers a range of needs and rights children have in
relation to interaction with others. These areas include the right to their
own identity,; education/schooling (Hyperlink Heading: ‘Education’);
participation (Hyperlink Section: ‘Participation ), understanding,
information and communication and counseling/supportive services
(Hyperlink Subsection: ‘Counseling’).
4. Self-actualisation: This area covers a child’s need for recreation/idleness
and freedom of expression.
16
2.3.3 Working with Others
This section looks at ways in which organisations can work with other groups
conducting activities aimed at orphans and vulnerable children. It is part of
improving work (Hyperlink Section: Improving the Work’). Related sections
include working with volunteers (Hyperlink Subsection: ‘Working with
Volunteers’) and monitoring and evaluation (Hyperlink Subsection: ‘Monitoring
and Evaluation’).
Key points about working with others are:
1. Links to other organisations can be very useful in learning about what others
are doing. This can be extremely helpful in improving practice.
2. Working with others may take many forms. It may consist of informal
linkages, official networks and formal partnerships
Reasons for Working with Others
Organisations often find it useful to develop linkages with other organizations.
Reasons for this vary. First, it provides organisations with ways of sharing
information about what they are doing and learning about what others are doing.
This may be done in a number of different ways including electronic and print
media, meetings and site visits. Such learhing can be helpful in improving an
organisation’s work. In addition, such linkages provide encouragement for staff
and volunteers in organizations who often feel they are working in isolation.
They also provide opportunity for organisations to work constructively together.
Such joint working may result in improved services for orphans and vulnerable
children.
Types of Relationships between Organisations
Relationships between organisations take many forms. These include:
•
•
•
Informal links — such as exchange visits for staff and volunteers
Formal networks - such as the Children in Need Network (CHIN) in Zambia
Formal partnerships - where two or more organisations agree to work
together on a particular activity
I7
3. Health and Nutrition
This section looks at the health and nutrition of orphans and vulnerable children.
It looks at ways in which the effects of HIV/AIDS on the health and nutrition of
children can be measured and the ways in which HIV/AIDS causes its effects on
the health and nutrition of orphans and vulnerable children. It also looks at what
rights (Hyperlink Heading: ’Children’s Rights') orphans and vulnerable children
have regarding health and nutrition and what actions can be taken to improve
their health and nutrition. Other sections look in more detail at health and
nutrition of orphans and vulnerable children, in general, (Hyperlink section.
All Children’) and children living with HIV/AIDS (Hyperlink Section: Children
living with HIV/AIDS'), in particular.
Key points about health and nutrition are:
1.
HIV/AIDS is having severe effects on the health and nutrition of children. In
countries with severe HIV/AIDS epidemics, this is seen in increasing rates of
under 5 mortality.
2. HIV/AIDS affects the health of children directly and indirectly.
3. It is possible to approach this issue by considering the rights (Hyperlink
Heading: 'Children’s Rights') that children have regarding health, and
examining how these rights are abused in relation to HIV/AIDS.
4. Ways in which the effects of HIV/AIDS on the health of children can be
reduced include effective HIV prevention; health education for children and
caregivers; strengthening nutrition (Hyperlink Subsection: ‘Nutrition and
Access to Food ) and food production; and improving access to health
services (Hyperlink Subsection: ‘Access to Health Care') in general and
antiretrovirals (Hyperlink Subsection: “Access to Treatment’), in particular.
r
Effects of HIV/AIDS
HIV/AIDS is having severe effects on the health and nutrition of children. In
countries with severe HIV/AIDS epidemics, this is seen in increasing rates of
under 5 mortality. In some other countries, with lower rates of infection, under 5
mortality rates have either not risen or fallen as a result of other factors.
HIV/AIDS affects the health-of children in a number of different ways including.
.
Directly, when children themselves are infected with HIV (Hyperlink
Section: ‘Children living with HIV/AIDS’).
•
By making children more vulnerable to other infections. For example,
children, in general, are more vulnerable-to tuberculosis as a result of
IS
HIV/AIDS because of greater exposure to the disease. Children living with
HIV/AIDS are more vulnerable to tuberculosis because of reduced immunity
•
Through the impoverishing effects of HIV/AIDS. One of the impacts of
HIV/AIDS on children, their families and communities is worsening poverty
(Hyperlink Section: 'Situation'). This affects the health and nutrition of
children in a number of ways. Families are less able to afford health care and
other measures to prevent disease, such as the purchase of mosquito nets.
In addition, poor people often have poorer nutrition, housing, hygiene and
water. All these have effects on the health of children.
•
Orphans and vulnerable children are more likely to be involved in work. Such
child labour (Hyperlink Section: 'Child Labour’) is often unregulated and may
expose them to a variety of hazards, including chemicals and pesticides.
•
Orphans and vulnerable children may be less able to access health care
(Hyperlink Section: Access to Health Care ) than other children due to a
variety of reasons.
•
HIV/AIDS has reduced the ability of health systems to cope and deliver
services. This is because of the increased demand for services as a result of
HIV/AIDS and the reduced ability to deliver services because of illness and
death of health personnel.
•
HIV/AIDS has negative effects on the gtowth and development of children.
Causes of this include poverty and illness of the parent and/or the child.
Children’s Health Rights
The Convention on the Rights of the Child (Hyperlink Heading: 'Children's
Rights’) includes specific rights regarding health. Examples of these include the
right to medical confidentiality, the right to informed consent and the right to
access to basic health care services. In many situations, orphans and vulnerable
children do not enjoy the benefits of these rights.
Reducing the Effects of HIV/AIDS on Children’s Health
There are many different ways in which the effects of HIV/AIDS on the health of
children can be reduced. These include:
•
By promoting effective methods to prevent the further spread of HIV/AIDS.
•
Through health education of children and their caregivers.
•
Through a variety of measures which make health services more
accessible (Hyperlink Section: 'Access to Health Care’) and appropriate for
19
children Provision of effective health services for children's caregivers will
also have effects on the health of children.
•
Improving access to treatment with antiretroviral drugs (Hyperlink
Subsection: Access to Treatment').
•
Steps to improve children’s nutrition, including initiatives to strengthen
household food production.
20
3.1. All Children
This section looks at issues which affect the health and nutrition (3) of all
orphans and vulnerable children. This is distinct from issues affecting children
living with HIV/AIDS (3.2). More details are available in other sections on
nutrition (3.1.1) and access to health care (3.1.2).
Key points about health and nutrition (3) are:
1. HIV/AIDS is having severe effects on the health and nutrition of children. In
countries with severe HIV/AIDS epidemics, this is seen in increasing rates of
under 5 mortality.
2. HIV/AIDS affects the health of children directly and indirectly.
3. It is possible to approach this issue by considering the rights (Hyperlink
Heading: ‘Children’s Rights’) that children have regarding health, and
examining how these rights are abused in relation to HIV/AIDS.
4. Ways in which the effects of HIV/AIDS on the health of children can be
reduced include effective HIV prevention; health education for children and
caregivers; strengthening nutrition (Hyperlink Subsection: ‘Nutrition and
Access to Food’) and food production; and improving access to health
services (Hyperlink Subsection: ‘Access to Health Care ) in general and
antiretrovirals (Hyperlink Subsection: Access to Treatment ), in particular.
More details on these key points are available in the section on health and
nutrition (3).
Research from Zambia has shown that some children orphaned by HIV/AIDS are
more at risk of problems with health and nutrition than others:
•
Younger children are more at risk than older children.
•
Children living in large families in rural areas are more at risk than those in
smaller families. This may not be true in urban areas.
•
Children in poor families are more at risk.
•
Paternal orphans living with their mother are more at risk of health problems
than maternal orphans living with their father. This stresses the need to
consider paternal orphans (1.1) when working with orphans and vulnerable
children.
21
3.1.1 Nutrition and Access to Food
This section looks at issues which affect the nutrition of orphans and vulnerable
children and their access to food. Other sections cover general issues of health
and nutrition (3.1) and details of access to health care (3.1 2)
Key points about nutrition are:
8. Good nutrition is essential for the physical growth and development of
children. It is also necessary for full development of their immune system.
9. Certain groups of children are particularly vulnerable to nutrition problems.
These include young children (3.1) and children living with HIV/AIDS
(3.2).
”
10. Children’s need for good nutrition starts before they are born. Children of
different ages have different nutritional needs.
11. HIV is known to be transmitted from mother to child through breastfeeding.
However, children are more at risk of other infections if they do not breast
feed. Things to consider when a woman decides how to feed her baby
include whether or not she knows her HIV status and whether or not she is
able to safely feed her baby in another way.
Good nutrition is essential for the physical growth and development of children. It
is also necessary for full development of their immune system.
Certain groups of children are particularly vulnerable to nutrition problems.
These include young children (3.1) and children living with HIV/AIDS (3.2)
Children’s need for good nutrition starts before they are born. Children of
different ages have different nutritional needs. Young children are particularly at
risk of problems with nutrition. For this reason, many of the documents focus on
the nutrition of children under the age of five years. These children can also be
broken down into groups, 0-6 months, 6-11 months, 12-23 months and 24
months to 5 years.
Issues to consider in the nutrition of children under the age of 5 include:
•
The role of breastfeeding. It is well-known that breastfeeding is very good
for children. It protects them against many diseases and greatly increases
their chances of survival. However, it is known that breast milk can transmit
HIV. Deciding on how to feed an infant can be very difficult for women
because of HIV. This choice will depend on whether the woman knows if she
is HIV positive and whether or not she can safely feed her baby in another
22
way. Policy principles on infant feeding (0000175e00) were agreed by
leading UN agencies in 2002. Approaches to infant feeding form an important
part of measures to prevent mother to child transmission (PMTCT) of HIV.
However, there are other important steps which need to be taken, including
preventing HIV infection in women, preventing unintended pregnancy and
providing long-term support to women.
•
Other foods. Children need other foods apart from breast milk from the age
of 3-6 months. There is some evidence that exclusive breastfeeding before
that time reduces the risk of transmission of HIV from an HIV positive mother.
Children need a range of nutrients including those which provide energy and
a range of ‘micronutrients’. Important micronutrients include vitamin A, iron
and vitamin C.
•
Feeding practices can affect whether or not a child is well-nourished. A
child should be provided with food they can digest on their own plate. Good
hygiene is very important when preparing food for children. Particular care is
needed to ensure that a child continues to receive nutrients when they are ill.
•
Access to food. Many documents which talk about nutrition of children
overlook a key problem. Many families do not have enough food throughout
the year. They do not always have the right kinds of food. Ensuring children
and families have enough food is important to ensure that orphans and
vulnerable children are well-nourished. Community grain banks are one way
in which communities can provide ‘safety nets’ for vulnerable children.
2.3
3.1.2 Access to Health Care
from accessing education (4 2 1).
Key barriers to access to
health care for orphans and vulnerable children are.
1. Lack of money
2.
Distance to the health facility and availability of transport
3. Lack of time to seek health care
4. Negative
attitudes and limited skills of some health workers
5. Lack of a family care giver
6.
Lack of health knowledge among children and care givers
Money
Lack of money is a major reason why
SaSfhX^X^^iSS^ayiose income
if they spend time seeking health care.
Distance to Health Facilities
EsSSsSjSBSsS
a barrier.
Time
them taking a child to the health centre.
Health Workers
24
Children and their care givers may not use health services because they fear
they will not be treated well by health workers. This may be because of negative
attitudes among health workers. Health workers may also lack skills to deal
effectively with orphans and vulnerable children. In some cases, people with HIV
are not given treatment or are given a lower standard of treatment. There may
also be fears that information about health will not remain confidential or that they
will have to explain frequent trips for health care.
Care Givers
There may be other reasons why a parent or other adult care giver is unable to
take a child for health care. For example, they may be ill themselves and unable
to do this. Children in child-headed households (7.1.2) may have no adult to
take them for health care. In some cases, adults may feel it is not worth spending
time and resources on health care for children, particularly if they have HIV. Also,
some adult guardians may prioritise the needs of their own child rather than
others that they care for.
Knowledge
Care givers may lack the skills and knowledge on health issues. For example,
they may not know when to take a child to a health centre. This may be a
particular problem when the care giver is a grandparent or older child because
much health education about children is targeted at mothers.
25
3.2 Children Living with HIV/AIDS
This section looks at health and nutrition issues which particularly affect children
living with HIV/AIDS. More general issues of health and nutrition (3) and how
they affect all orphans and vulnerable children (3.1) are covered in other
sections. Other sections give more details on access to antiretroviral treatment
(3.2.1) in children, which drugs to use (3.2.2) in children and practical tips
(3.2.3) on how to give such treatment in children.
Key points about the health and nutrition of children living with HIV/AIDS are:
1. UNAIDS estimates that 1500 children per day are being infected with HIV
globally.
2. Most HIV infection in children occurs through mother to child transmission
(MTCT). Other routes of infection include through sexual activity and unsafe
health practices.
3. It is difficult to test children under the age of 15-18 months for HIV. Children
born to HIV positive women have HIV antibodies from their mother in their
blood until this age.
4. HIV has serious effects on the health of children. They often grow poorly and
are more at risk of infectious diseases. These are often more severe than in
other children.
5. Without treatment, 60-75% of children with HIV die before the age of five
years. With effective antiretroviral treatment, this figure can be reduced below
20%.
6. Children with HIV have a range of health needs in addition to access to
antiretroviral treatment. These include immunization and prevention and early
treatment of all infections.
In this section, the term children living with HIV/AIDS is used to mean HIV
positive children. However, some documents use the term more broadly to
describe all children (3.1) who are affected by HIV/AIDS.
UNAIDS estimates that 1500 children per day are being infected with HIV
globally.
Routes of Transmission
Most HIV infection in children occurs through mother to child transmission
(MTCT). This can occur during pregnancy, at the time of birth or through
26
breastfeeding (3.1.1). In developing countries, approximately one in every three
children born to an HIV positive mother is themselves infected with HIV. In
developed countries, less than one child in fifty born to an HIV positive mother is
themselves infected. This is because of health practices including delivery by
Caesarean Section, treatment with antiretroviral drugs and safe alternatives to
breastfeeding. Children may also be infected with HIV through sex and unsafe
health practices. Sexual spread of HIV (4.2.2) is most common in older children
but can occur in younger children through sexual abuse (8.3). Unsafe health
practices include use of non-sterile needles and unsafe blood products. These
practices may also occur in the traditional health sector and include activities
such as circumcision and ear piercing.
HIV Testing in Children
It is difficult to test children under the age of 15-18 months for HIV. Standard HIV
tests detect antibodies to HIV. Children born to HIV positive women have HIV
antibodies from their mother in their blood until this age. These are called
maternal antibodies. In some cases, these maternal antibodies are found in the
blood of children aged more than 18 months. It is possible to detect HIV directly.
However, these tests are very expensive and not widely available in developing
countries. The test used is the HIV DNA polymerase chain reaction (PCR). In the
United States, children born to HIV positive mothers receive PCR tests at birth
and again at 1-2 months and at 4-6 months. Two positive tests are taken as
evidence of HIV infection. Two negative tests are evidence that the child does
not have HIV infection. This can be confirmed using standard HIV antibody tests,
which become negative after the age of about 18 months.
There are many issues to consider before testing a child for HIV:
•
HIV testing should only be carried out if it brings some clear benefit to the
child. For example, this might be if it results in better care and support.
•
Counselling needs to be provided for children and their care givers. The
counseling provided should be appropriate for the age of the child.
•
HIV testing needs to be carried out in a way which ensures that results are
kept confidential.
It is also possible to decide how severe a child’s HIV infection is. This is done by
assessing two factors:
• Symptoms: The presence and severity of symptoms can be used to assess
how severe a child’s infection is.
• CD4 count: CD4 cells are a particular type of white blood cell. They form part
of the body’s immune system. Tests which count these can show how well
27
the immune system is working. In children, age-adjusted tables need to be
used for assessing CD4 counts. This is because there are more CD4 cells in
the body at birth. These levels fall during childhood to reach adult levels at
about 13 years of age.
Effects of HIV Infection on Children
HIV infection affects children in a number of ways:
•
Children with HIV infection often fail to grow properly. This is sometimes
referred to as failure to thrive.
•
Children with HIV infection are more frequently affected by infectious
diseases. These are often more severe than in other children.
•
Without treatment, 60-75% of children with HIV die before the age of 5 years.
With treatment with antiretroviral drugs (3.2.1), this figure can be reduced to
about 20%.
•
Children with HIV often face stigma and discrimination (8.2) as a result of
their infection.
Other routes of infection include through sexual activity and unsafe health
practices.
Health Needs of Children Living with HIV
Children with HIV have a variety of health needs. These include:
•
Treatment (3.2.1) of their HIV infection.
•
Medicines which can prevent common infections occurring. This is called
prophylaxis.
•
Early and effective treatment of common infections.
•
Immunisation. Children with HIV/AIDS should receive immunizations in the
same way as other children. These help protect the child against infectious
diseases.
•
Good nutrition
•
Good hygiene
•
A balance between exercise and rest
28
•
Psychosocial Support
including care, comfort and counselling
29
3.2.1 Access to Treatment
This section looks at issues concerning the access of children with HIV (3.2) to
effective treatment. Other sections look at which antiretroviral drugs (3.2.2)
should be used and provide practical treatment tips (3.2.3).
Key points about access to treatment for HIV are:
1. Effective antiretroviral drugs have been available since 1996. Using several of
these drugs together in combination has greatly increased survival of people
with HIV in developed countries.
2. It is estimated that more than 6 million people in developing countries need
antiretroviral treatment. However, only around 230 000 people receive this
treatment.
3. One of the main barriers to treatment has been its cost. This has been
particularly high because of the high costs of the drugs and the fact that a
person needs to take several of these over a long period. However, prices of
antiretroviral drugs have fallen dramatically since 2000.
4. There are other barriers to treatment in developing countries. These include
the lack of sufficient health infrastructure, lack of sufficient trained staff and
lack of national policies which promote antiretroviral treatment from a public
health approach.
Access to Antiretroviral Drugs
Effective antiretroviral drugs have been available since 1996. Using several of
these drugs together in combination has greatly increased survival of people with
HIV in developed countries. These drugs do not ‘cure’ HIV. They do control the
disease which means that people living with HIV live longer and have a better
quality of life. They do have to be taken for life and can have severe side-effects.
Unfortunately, very few people in developing countries currently receive these
drugs. It is estimated that more than 6 million people in developing countries
need antiretroviral treatment. However, only around 230 000 people receive this
treatment. Most of these live in one country, Brazil. The World Health
Organisation has set a target that more than 3 million people in developing
countries should be receiving these drugs by 2005.
Barriers to Access - Cost
The main barrier to access to this treatment has been its cost. This was
estimated at $10-15 000 per year. This was not only because of the high cost of
30
the drugs but also because a person needs to take more than one drug for a long
period. However, drug prices have fallen dramatically since 2000. Treatment may
now cost as little as $350 per year. This has occurred for several reasons. These
include:
•
Generic Production - Many of the antiretroviral drugs that are available are
produced by drug companies. These companies seek to protect their new
drugs through a system of ‘patents’. These patents are laws which prevent
other companies ‘copying’ the drug. Drugs protected by patents are
sometimes called proprietary drugs. Drugs that are not protected by patents
are called ‘generic’. Some countries (Brazil, India, Thailand) have produced
‘generic’ versions of antiretroviral drugs at much lower prices than the
proprietary drugs. As a result of this competition, drug companies have
greatly reduced prices of their proprietary drugs.
•
Differential Pricing/Discounting - This involves companies selling their
drugs at a lower price in developing countries than in developed ones. This
only works if the markets can be kept separate. It relies on the good will of
drug companies. They may only agree to this if countries agree to stricter
rules on patents and other forms of ‘intellectual protection’.
•
TRIPS Safeguards - TRIPS (Trade-related aspects of Intellectual Property
Rights) is one of the rules of the World Trade Organisation (WTO). Its aim is
to ensure that rules on intellectual property rights are applied throughout the
world. Many countries are currently able to produce and use generic
antiretroviral drugs because their national laws do not recognise patents on
these drugs. There is international pressure for countries to adopt the
provisions of TRIPS which would make these patents apply in all countries.
However, TRIPS allows for countries to overrule these patents when it is
needed to promote ‘public health’. This can be done through ‘compulsory
licencing’ which allows a country to make or buy a generic version of a
proprietary drug when it is needed for public health reasons. Buying such a
generic drug from another country is called ‘parallel importing’.
•
Regional/lnternational Procurement - Drug costs can be reduced when
they are purchased in bulk. This can be done where countries purchase
jointly with other countries in their region. International arrangements have
been used for other medicines, such as vaccines. Currently, there is no
international system for purchasing antiretroviral drugs.
•
Local Production through Voluntary Licencing - This involves a country
and a drug company agreeing to allow the drug to be manufactured in that
country. This will require the transfer of technology from the drug company to
the country.
31
Drug Donations - These may improve short-term access to a drug
However, they may hinder changes needed to ensure these drugs remain
available over time. They may stop countries producing their own medicines.
In addition, such donations usually only benefit a few people in a few
countries.
•
Other Barriers to Access
Other major barriers to access to antiretroviral drugs include the lack of health
infrastructure and adequately trained staff in developing countries. This is
particularly important with antiretroviral drugs because they are complex and
difficult to take, it is difficult to select and monitor patients and there is a risk of
resistance developing.
One major part of health infrastructure is the availability of laboratory facilities.
The World Health Organisation has identified four levels of such facilities
minimum, basic, desirable and optional. The minimum level requires the ability to
measure haemoglobin and to test for HIV antibodies. Currently, only the
minimum level is required to be able to start antiretroviral treatment programmes.
Expanding Access to Treatment
The following steps will be helpful in expanding treatment with antiretroviral
drugs:
•
Starting small and gradually expanding.
•
Securing additional resources so that funds are not diverted away from other
parts of the health service.
•
Adopting national policies which have a public health approach. These
include having an agreed, simplified first line treatment regime and ensuring a
continuous drug supply.
•
Training health staff at all levels in how to provide this treatment.
•
Ensuring that work is carried out in both public and private sectors.
•
Developing a national system for monitoring drug resistance.
32
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3.2.2 Which Drugs?
This section looks at issues affecting the choice of antiretroviral drugs to treat
children with HIV (3.2). Other sections look at general issues regarding access
to treatment (3.2.1) and provide practical treatment tips (3.2 3).
Key points about choosing antiretroviral drugs in children are:
1. There are many differences between children and adults regarding HIV
infection and its treatment. Evidence is unclear about whether treatment of
HIV in children is as effective as in adults.
2. Recommendations about when to start treatment differ between the United
States and Europe. World Health Organisation guidelines for developing
countries broadly follow European guidelines.
3. There are very many different antiretroviral drugs available. They are in three
main categories - Nucleoside Reverse Transcriptase Inhibitors (NRTIs), NonNucleoside Reverse Transcriptase Inhibitors (NNRTIs) and Protease
Inhibitors (Pls).
4. All treatment plans now use a combination of at least three drugs. These
usually include two NRTIs and one from another group.
5. A wide range of issues need to be considered when deciding which drugs to
use. Some of these are general while others apply particularly to children. It is
helpful if a country has one combination of drugs which it uses for first treating
people with HIV. This is called the primary regime. Other drug combinations
may be needed for people who experience side-effects or do not respond to
the primary treatment. These combinations are called secondary regimes.
6. Dosages for children are calculated either based on the surface area of a
child or its weight. Special formulations of drugs are needed for children.
Breaking tablets for children is not recommended.
7. Children who have TB should usually complete their TB treatment before
starting treatment with antiretroviral drugs.
8. Cotrimoxazole should be given to all children born to HIV positive mothers in
the first 6-12 months of life. This is to prevent pneumocystis pneumonia.
Differences between Adults and Children
There are many differences between children and adults regarding HIV infection
and its treatment. Diagnosis of HIV infection is difficult in children under 18
months of age. This is because they still have antibodies from their mother
(3.2) in their blood. It may be more difficult to measure disease progress in
children using laboratory tests. This is because levels of viral load and CD4 cells
are very different in children as compared to adults. Some studies have
suggested that treatment of HIV in children is less effective than in adults. Other
studies have shown that treatment of children is just as effective as in adults.
This means that the current position is unclear.
When to Start Treatment
Recommendations about when to start treatment differ between the United
States and Europe. World Health Organisation guidelines for developing
countries broadly follow European guidelines. These are shown in the table
below:
WHO Staging System
Child under 18
months of age who
has had HIV infection
confirmed by
laboratory test (PCR)
WHO stage III
disease OR
WHO stage I or II
disease with a CD4
percentage <20%
Child under 18
months of age who
has not had HIV
infection confirmed by
laboratory test (PCR)
WHO stage III
disease and CD4
percentage <20%
Child over the age of
18 months who has a
positive HIV antibody
test
WHO stage III
disease OR
WHO stage I or II
disease with a CD4
percentage <15%
Stage I - Asymptomatic or
generalised
lymphadenopathy
Stage II - Unexplained,
chronic diarrhea; severe or
persistent candidiasis
outside the neonatal
period; weight loss or
failure to thrive; persistent
fever or recurrent severe
bacterial infections
Stage III - AIDS-defining
opportunistic infections,
severe failure to thrive,
progressive
encephalopathy,
malignancy or recurrent
septicaemia/meningitis
In practice, this means that different approaches are needed depending on
whether the child is over the age of 18 months. Under that age, it will probably
not be possible to be sure that the child has HIV infection. In that case, treatment
is only recommended for those who are very ill (stage III) and have evidence of
damage to their immune system (CD4percentage <20%). If the child is over the
age of 18 months, treatment should only be given to children who have had a
positive antibody test. It can then be given to all those who are very ill (stage III)
34
and those who are less ill (stages I and II) but have evidence of a damaged
immune system (CD4 percentage <15%).
Drug Types and Names
There are so many different antiretroviral drugs available that it can be very
difficult to understand articles which describe ways in which they are use.
Antiretroviral drugs have a variety of names:
• Trade or Proprietary Name: This is the name given to a particular version of
a drug produced by a particular company. These names should not be used
when describing or prescribing drugs. Some tablets contain more than one
active drug. These drugs are often known by their trade names but it is better
to describe them using their generic names or abbreviations.
• Generic Name: This is the name of the drug which is used by everyone that
makes it. This is the name that should be used when describing the drug.
• Abbreviations: The generic names of most antiretroviral drugs are very long
This makes them hard to remember and use. Most of them have been given
abbreviations which are made up of three letters or numbers. Some have
more than one abbreviation. For example, AZT and ZDV both refer to
Zidovudine.
Antiretroviral drugs can be grouped into three main types according to how they
work. There are Nucleoside Reverse Transcriptase Inhibitors (NRTIs), NonNucleoside Reverse Transcriptase Inhibitors (NNRTIs) and Protease Inhibitors
(Pls). A table showing the names of drugs in these categories is shown below:
NRTIs
Pis
NNRTIs
Zidovudine (AZT/ZDV)
Didanosine (ddl)
Stavudine (d4T)
Lamivudine (3TC)
Zalcitabine (ddC)
Ritonavir
Nelfinavir (NFV)
Amprenavir
Lopinavir (LPV)
Indinavir (IDV)
Saquinavir (SQV)
Nevirapine (NVP)
Efavirenz (EFZ)
Abacavir (ABC) (In some papers this is
grouped with NRTIs)
Delavirdine
35
Combination Therapies
All treatment plans now use a combination of at least three drugs. These usually
include two NRTIs and one from another group. There is now no place for
treatment with one or two drugs only. Countries should develop their own
policies on which drugs to use in primary and secondary treatment regimes.
Where these exist they should be followed.
Factors to be considered in choosing drugs for the primary treatment regime
include:
•
Potency - that is the effectiveness or power of the drugs. For example,
NNRTIs are not effective against HIV2.
Side-effects
•
Interactions with other drugs - for example Zidovudine and Stavudine can not
be used together
•
Potential for future treatment options
•
Adherence - some drugs require precise timings and large numbers of tablets
to be taken.
Coexistent conditions
•
Risks in children and pregnant women - for example, Efavirenz can not be
taken in pregnancy or by children under the age of 3
Risk of resistance
•
Cost and other access issues
•
Suitability of each drug for use in areas of limited health infrastructure
•
Ease of transport - some drugs require storage in glass containers and/or
refrigeration
•
The existence of different groups and sub-types of HIV
•
The availability of formulations suitable for small children, such as liquids. It is
not recommended to break adult tablets for children.
•
In the case of children, whether or not mothers have received antiretrovirals
during pregnancy. Current evidence suggests that this does not need to be
taken into account when choosing drug regimes'
36
One primary treatment regime suggested by WHO is Zildovudine, Lamividine
and Abacavir. Secondary treatment regimes usually use two different NRTIs and
a drug from a different category. This would mean that if a PI is used in the
primary treatment regime, an NNRTI would be used in the secondary regime.
Secondary regimes are required for people whose disease does not respond to
the primary regime and those who experience side effects from the primary
regime.
Dosage of Antiretroviral Drugs in Children
It is important to calculate the dose of antiretroviral drugs accurately for children.
Many documents advise doing this on the basis of surface area. However, it is
not possible to measure a child’s surface area directly. This has to be calculated
from measurements of height and weight using formulae or charts. In some
cases, dosages can be calculated from a child’s weight. ‘Drug tables’ can assist
with these calculations and help to avoid errors.
Other Issues
A few general issues are considered here:
•
Children who have TB should usually complete their TB treatment before
starting treatment with antiretroviral drugs. This is because of the risk of
harmful interactions with the TB drug, Rifampicin.
•
Cotrimoxazole can be used to prevent children with HIV becoming ill with
pneumocystis pneumonia (PCP). This is called PCP prophylaxis. It is
recommended in all children born to HIV positive mothers for 6-12 months.
•
Work is currently being undertaken to integrate issues relating to HIV into the
approach to childhood illness currently recommended by the World Health
Organisation. This is called the integrated management of childhood illnesses
(IMCI).
37
3.2.3 Practical Treatment Tips
This section looks at ways in which children with HIV (3.2) can be assisted to
take their antiretroviral drugs properly. Other sections cover issues regarding
access to treatment (3.2.1) and provide which antiretroviral drugs to use
(3.2.3).
Key points about treatment with antiretroviral drugs in children in practice are:
If antiretroviral drugs are to work properly they need to be taken regularly and
in certain ways. Taking drugs in the required way is called ‘adherence’ or
1
‘compliance’.
2. There are many reasons why people fail to adhere to the treatment
schedules.
3. There are a number of practical ways in which children can be helped to
adhere to treatment schedules.
4
In addition to their medicines, sick children and adults require a great deal of
care and comfort. Much of this is provided by family members in the home.
Why is Treatment Adherence so Important?
If antiretroviral drugs are to work properly they need to be taken regularly and in
certain ways. Taking drugs in the required way is called ‘adherence or
‘compliance’.
Problems with Taking Antiretroviral Medicines
There are many reasons why people fail to adhere to the treatment schedules.
These include:
. Some medicines, such as Stavudine, Didanosine and Ritonavir need to be
stored in a refrigerator.
. Some medicines need to be taken on an empty stomach. This means taking
them either one hour before food or two hours after. These include Indinavir
and Didanosine. In.addition, these two drugs need to be taken one hour apart
from each other. Some medicines need to be taken with food. These include
Nelfinavir, Saquianvir and Lopinavir.
• Some medicines interact with each other. One may stop the other from
working. They may also make side-effects more likely.
38
• Some medicines taste bad. Their taste can be improved by mixing with food,
such as milk. Examples include Nelfinavir and Ritonavir.
• Some capsules are very large and difficult to swallow.
• It is difficult to remember to take a medicine several times a day every day. It
may be difficult to fit this into schedules, such as going to school. Children
may not wish to take medicines in public.
• Some medicines cause side-effects which make the child feel ill. They may
not wish to take the medicine for this reason.
*
• It is difficult to calculate dosages based on surface area. It is easier to use
weight. Dosages need to be increased as the child grows.
Some projects have lists of questions that adults can answer to check that a child
is taking their medicines correctly.
Practical Ways of Improving Adherence
There are several practical ways of helping a child stick to their treatment
schedule. These include:
• Producing a schedule for taking all the medicines. This should fit in with the
family’s schedule, including mealtimes. ‘
• Finding ways of reminding children and their care givers when doses are due.
This may include sticking the schedule somewhere that it can be easily seen.
Alarm clocks and watches can be used to remind when doses are due.
• Having a way of recording when each dose has been given. This may include
a version of the schedule with boxes that can be ticked.
• Coloured bottles to show which medicine is which.
• Special dosing cups, measuring spoons or oral syringes to help ensure that
the right dose is given.
• Packing drugs into packages sufficient for one week. It is then possible to
check at the end of the week that all medicines have been taken.
• Being positive and encouraging in dealing with the child.
• Ensuring that an adult is involved with the child in taking the medicine. This is
particularly important for measuring the amount to be taken by small children.
39
Adults should also check that children have swallowed the medicine they
have been given.
. Finding ways of improving the taste of some medicines. This may include
mixing the medicine with something or taking something with a better taste
after the medicine. Chilling a medicine may make it taste better.
. Involving the child in taking their own medicines. This is particularly important
as the child gets older.
. Using medicines which can be given once per day rather than those that have
to be given more often.
• Using dosage tables which show how to calculate the dosage of medicines
from the weight of the child.
. Discussing any possible side-effects of the medicines with health staff.
. Informing health staff of any problems in taking the medicines. This includes
informing them of any missed doses.
Care and Comfort
In addition to their medicines, sick children and adults require a great deal of care
and comfort. Much of this is provided by family members in the home. Elements
J
of care and comfort include:
•
Listening, talking and touching
•
Dealing with past concerns
•
Planning for the future
•
Providing water and food
•
Washing
•
Changing the person’s position in bed. Rubbing Vaseline on the skin
•
Encouraging rest and exercise
•
Avoiding getting or spreading any infections
•
Treatment of common diseases, such as diarrhoea
•
Taking to a clinic
40
•
Buying medicines and assisting the person to take them
V
41
4 Education
This section looks at education issues which affect orphans and vulnerable
children. Other sections look in more detail at issues relating to early childhood
development (4.1) and school age children (4.2).
Key points about education and orphans and vulnerable children are.
1. Education is vital to the development of children in a number of ways.
2.
HIV/AIDS is having serious effects on the education sector. Many teachers
are sick or have died. The cost of education is also increasing because of the
need to train more teachers.
Orphans and vulnerable children, particularly girls, may miss out on
3. educational opportunities. They may also not perform to their ^' educational
potential. They may also face stigma and discrimination (8.2) in sch
4
The Convention on the Rights of the Child (8) has many implications for
education. Relevant rights include the rights to equality, basic education,
privacy, an environment that promoted health and access to information.
Importance of Education
Education is vital to the development of children in a number of ways. It aids their
psychosocial development. It is vital for their future opportunities. It helps reduce
their risks and vulnerabilities. For example, it can contribute to reducing their
risks of contracting HIV infection.
Effects of HIV/AIDS on the Education Sector
Documents in this section do not all agree on the effects of HIV on the education
sector Some claim that it is having severe effects. The effects that are claimed
occur because of the level of HIV infection among teachers. This leads> to
increased absenteeism through ill-health and attending funerals. Th.s affects the
quality of education provided. As teachers die of AIDS, this reduces the■ ^mber
of teachers available. It also increases the cost of education because of the need
to train more staff to replace those that have died. Some argue that teachers
should be a priority for receiving treatment with antiretroviral drugs becaus
the important role they play in providing education to children.
Others claim that there is little real evidence of these effects in studies which
have been done to document the consequences of HIV/AIDS on the education
sector. They argue that the number of teachers needed is declining because of a
decline in the number of learners in school.
42
Effects of HIV/AIDS on Children’s Education
Orphans and vulnerable children, particularly girls, may miss out on educational
opportunities. Reasons for this are considered in more detail in a section which
explores issues of access to education (4.2.1). They may also not perform to
their full educational potential. They may also face stigma and discrimination
(8.2) in school.
Children’s Education Rights
The Convention on the Rights of the Child (8) has many implications for
education. Relevant rights include the rights to equality, basic education, privacy,
an environment that promoted health and access to information.
e
43
4.1 Early Childhood Development
This section looks at issues related to HIV/AIDS that affect early childhood
development. Another section looks in general at issues relating to education
(4). Another section looks in more detail at issues relating to school age
children (4.2).
Early childhood is a period during which children learn and develop extremely
rapidly. This development depends on a number of key factors including health,
education, stimulation and interaction. Interventions at this stage have been
shown to have great benefits for children including:
• Higher intelligence scores
• Higher and timelier school enrollment
• Less grade repetition and lower dropout rates
• Higher school completion rates
• Improved nutrition and health status
• Improved social and emotional behavior
• Improved parent-child relationship
• Increased earning potential and economic self-sufficiency as an adult
• Increased female labor force participation
At a conference on Early Childhood Development in 2001, it was agreed that
HIV/AIDS was having serious effects on young children’s development. However,
it was agreed that relatively little was known about this because of the tendency
to focus on children between 0-18 years of age as one group.
44
4.2 School Age Children
.is section looks at the education (4) of orphans and vulnerable children of
school age. Anther sections looks at issues affecting younger children (4.1).
Other sections look in detail at access to education (4 2 1), HIV/AIDS and life
skills education (4 2 2) and the role of schools (4.2.3).
Key points about education and orphans and vulnerable children are:
1. Education is vital to the development of children in a number of ways.
2. HIV/AIDS is having serious effects on the education sector. Many teachers
are sick or have died. The cost of education is also increasing because of the
need to train more teachers.
3. Orphans and vulnerable children, particularly girls, may miss out on
educational opportunities. They may also not perform to their full educational
potential. They may also face stigma and discrimination (8.2) in school.
4. The Convention on the Rights of the Child (8) has many implications for
education. Relevant rights include the rights to equality, basic education,
privacy, an environment that promoted health and access to information.
More details on these key points are available in the section on education (4).
45
4.2.1 Access to Education
This section looks at issues which affect the access of orphans and vulnerable
children to education (4). Issues of access particularly affect school age
children (4.2). Other sections cover issues regarding HIV/AIDS and life skills
education (4.2.2) and the role of schools (4.2.3). Many of the barriers to
accessing education are the same as those which prevent children from
accessing health care (3.1.2).
Key points about the access of orphans and vulnerable children to education are:
1. Barriers to education are similar those which prevent access to health care.
They include lack of money, involvement of children in household duties,
stigma and discrimination (8.2), reduced education provision and quality,
low value placed on education by some families and the fear of infection.
2. There are a wide range of initiatives which have been tried to improve the
access of orphans and vulnerable children to education. These include
reducing costs, changing the way education is provided, increasing access to
education in other ways and improving educational quality.
3. A number of key principles have been established regarding access to
education. These are based on lessons learned from practical experience.
Barriers to Access to Education
Things which prevent orphans and vulnerable children gaining access to
education include:
• Cost of Education - Many poor families are unable to send their children to
school because of the costs involved. These may be direct costs, such as
school fees. They may also be indirect expenses, such as cost of uniform,
school supplies, transport and food.
• Household Duties - Many orphans and vulnerable children are expected to
spend considerable time in household duties. This may involve care for sick
adults and younger children. It may also involve contributions to household
livelihood. For example, this might involve agricultural or wage labour. In
some cases, children may be withdrawn from school to do such duties. This
withdrawal may be short or long-term. Girls are affected more than boys.
• Stigma and Discrimination (8.2) - Orphans and other vulnerable children
may experience stigma and discrimination in school. This may result in them
not attending school.
46
• Reduced Education Quality and Provision - HIV/AIDS is seriously
affecting the education sector (4) in severely-affected countries. Some
teachers are ill and dying from AIDS. This may be reducing the number of
teachers available to school and the quality of education provided by those
schools.
• Some Families do not Value Education - Some families may not see
education as a priority, particularly for girls and children with HIV. In many
cases, this is because they see survival needs as of higher priority.
• Fear of infection - This is particularly the case for children with HIV/AIDS.
However, children with HIV/AIDS are able to attend school normally.
Action to Improve Access to Education
Many activities have been introduced which seek to try to improve the access of
orphans and vulnerable children to education. These include:
• Reducing school-related costs - There are various ways of doing this.
These include eliminating school fees or meeting them in a different way.
They also include subsidising other expenses or providing in-kind support to
schools that admit orphans and vulnerable children. An example of such inkind support would be providing World Food Programme rations to children
through school.
• Changing the way education is provided through community schools,
interactive radio education and vocational training centres.
• Increasing access indirectly - This might involve strengthening the
economic position (6) of orphans and vulnerable children through
microfinance (6.1.3). This would make them more able to pay. Other indirect
methods include local advocacy (2.2.1) and building the capacity of
community care coalitions.
• Improving Educational Quality - This might involve adapting curricula to
make them more relevant to orphans and vulnerable children, training
teachers in meeting children’s psychosocial needs (5) and in using
community-based volunteers to support the work of teachers.
Key Principles
Key principles for increasing access to education include:
• Targeting all vulnerable children in an area, not just those affected by AIDS.
• Creating affordable schooling.
»
• Giving priority to non-formal education as well as formal education.
47
• Activities which are based on community need and community participation.
• Increasing management capacity at both national and community level.
• Linking short-term relief to longer-term policies.
• Ensuring safety at school for girls.
• Ensuring that increasing access to education also increases quality.
• Evaluating what works and what doesn’t and sharing this information.
48
4.2.2 HIV/AIDS Awareness and Life Skills
This section looks at HIV/AIDS education for orphans and vulnerable children.
This includes raising awareness about HIV/AIDS and practical training in life
skills. Other sections focus in general on education (4) and school age
children (4.2). Other sections cover issues regarding access to education
(4.2.1) and the role of schools (4.2.3).
Key points about HIV/AIDS awareness and life skills for orphans and vulnerable
children are:
1. Education about HIV/AIDS may take place in schools in several ways. It may
be included in the curriculum or in extra-curricular activities, such as AIDS
prevention clubs.
2. Information about HIV/AIDS is useful to children and young people. However,
information alone is not enough to overcome the risk of HIV infection.
Children and young people need to gain certain skills as well. These are
called life skills.
3. Life skills training in schools can be seen as part of a range of activities which
promote the health of children and young people.
4. A wide range of other activities may be used in schools to reduce vulnerability
to HIV infection. Some of these reduce vulnerability indirectly.
HIV/AIDS Education in Schools
Education about HIV/AIDS may take place in schools in several ways. It may be
included in the curriculum or in extra-curricular activities, such as AIDS
prevention clubs. This education needs to start before children become sexually
active. This means that it needs to start in primary school. Such education needs
to be appropriate for the age of the child. Teachers require training in order to
provide this education. This training needs to include use of participatory
methods. Children also learn a great deal from each other. Approaches which
use ‘peer education’ methods are based on this fact.
Life Skills
Information about HIV/AIDS is useful to children and young people. However,
information alone is not enough to overcome the risk of HIV infection. Children
and young people need to gain certain skills as well. These are called life skills.
Training in life skills usually involves participatory ways of learning, such as using
games. The aim of such training is to modify behaviour, not just to give
knowledge. Areas covered in life skills training include negotiation skills,
49
assertiveness, coping with peer pressure, compassion, self-esteem, tolerance
and social norms.
Health Promotion
Life skills training In schools can be
promote the health of children and young peopter Th
_anila(|0^ teaohi„g and
io P-O‘e hearth within the wider
^e"d“^
community.
Schoo, health promotion is
a'ndwork in "their
"oalth education but is more than just this
It also includes:
• A safe and healthy environment
• Good nutrition practices
• Good school health services
. Joint health action between the school and the community
Other Measures
include:
. Education itself. Children who revive at least nine years of education are
less vulnerable to sexual exploitation and HIV mfe
. Ensuring the quality of education and that it is relevant to local needs.
. Ensuring that girls have the same educational opportunities as boys.
problems in families and finding employment.
• Providing recreational and social services.
people into commercial sex activities.
50
• Developing supportive policies, such as those which promote children’s
rights (8).
*
51
.4.2.3 Strengthening Roles of Schools
This section looks at the various roles schools can play for orphans and
vulnerable children. Other sections focus in general on education (4) and
school age children (4.2). Other sections cover detailed issues regarding
access to education (4 2.1) and HIV/AIDS awareness and life skills (4.2.2).
Key roles which schools can play include:
1. Providing children with education (4) in general.
2. Providing children with education about HIV/AIDS in particular and training in
life skills (4.2.2).
3. Developing resiliency (5.1.2) in children. Schools have been identified as a
key place where this happens.
4. Activities which promote health (3).
5. Promoting and modeling a supportive and caring environment for orphans
and vulnerable children. This involves, in particular, tackling stigma and
discrimination (8.2).
6.
Providing practical support for orphans and vulnerable children. Schools are
well-placed to do this because of their daily contact with children who attend.
Teachers and other school staff need to be aware of sources of further
support for children.
7. Exerting influence in the local community. In many situations, teachers
occupy a position of great respect in a community. This gives them influence
to promote education and health within the community.
8. As a
a workplace for teachers. Many businesses are carrying out activities to
prevent the spread of HIV/AIDS among their work force. This can also be
done in schools.
52
A^'CPHE - SOCHAFiAX0!^
(
Koramangala
-""",ore
j
t
5 Psychosocial Support
This section looks at general issues regarding psychosocial support for orphans
and vulnerable children. Other sections look in more detail at the psychosocial
effects of HIV/AIDS (5.1) and various responses (5.2) to these.
Key points about psychosocial support for orphans and vulnerable children are:
1. Activities that support orphans and vulnerable children need to do more than
simply meet their physical needs. They also need to address their
psychological needs and needs for social interaction. These are termed
psychosocial needs.
2. HIV/AIDS has a wide range of psychosocial effects (5.1) on children.
3. There are several important principles (5.2) for responding effectively to the
psychosocial needs of orphans and vulnerable children. These have been
identified from practical experience.
4. One of the most important of these principles is that children are best cared
for in their own communities. Institutions (7.3.3) are particularly poor at
providing for children’s psychosocial needs.
5. Children living with HIV/AIDS (3.2) may have particular psychosocial needs.
Adults who provide care for orphans and vulnerable children also have
psychosocial needs.
What is Psychosocial Support?
Psychosocial support has been defined as an ongoing process of meeting
physical, emotional, social, mental and spiritual needs, all of which are
considered essential elements of meaningful and positive human development. It
goes beyond simply meeting children’s physical needs. It places great emphasis
on children’s psychological and emotional needs, and their need for social
interaction. Many programmes of support for orphans and vulnerable children
have focused almost completely on their physical needs only. Programmes which
aim to meet the psychosocial and physical needs of a child are called holistic.
Orphans and vulnerable children require psychosocial support because of the
trauma and stress they have experienced. Trauma is an emotional shock that
produces long-lasting, harmful effects on the individual. Parental illness and
death are causes of emotional trauma for children. Stress is an emotional
condition, experienced or felt when an individual has to cope with unsettling,
frustrating or harmful situations. It is a disturbing sense of helplessness, which is
uncomfortable and creates uncertainty and self-doubt. Psychosocial support
aims to help children cope with emotional trauma and stress.
53
5.1 Psychosocial Effects of HIV/AIDS
This section looks at the
general atle^ue0ofXchoso£ial
vulnerable children. Other sections look in ge
bereavement (5.1.1).and at
of circumstances.
Key psychosocial effects of HIV/AIDS on children are:
7, The effects of stress. Stress ® a^lJ^J^ngOfc“Sng'or harmful
helplessness, which Is uncomfortable
aXSes uncertainty and self-doubt,
8. The effects of earental-death (51 1)-
;e children who are in
g Poor sense of identity. This particularly
affecUJhosi
Trento;
adult relative who can help
SlSrthVr’owXTy -Within their own cuitore.
10 Behavioral Problems. Some children react to stress^beconn^B
aggressive, withdrawing, tak ng drug
they are facjng
Save Seen cSed ‘negative defence mechanisms,
11, Poor management of change. Pa^"[^Xthott parento may lack this
changes that occur in their hves.
wjth fami|y or community
XTtoXSX'Srly'a problem for children living in Institutions
(7.3.3).
Stress
Stress is an emotional condition,
^^^““['J'a’distwbing sense of
cope with unsettling, frustrating or harmful s
and self-doubt
helplessness, which is
are called ‘primary stress factors
Different things cause stress. S
f
mgy be made worse by othe
These include death or' s|C*ne
rsenjriq poverty, dropping out of school (4),
factors, such as loss of home, worsen g P^^Y
brothers gnd S1 sters.
stiflma^nd discrimination (8 ^
P, Children who are stressed often feel
sadnessX-3 CHd'S hea"h
de’el0Pn'en''
54
Parental Death
In many societies, people believe that children should be protected from death
because they are too young to understand what has happened. They may also
believe that children quickly forget about their parents. Although children do react
differently to the death of a parent, there are some feelings which children
commonly experience. These include:
• Guilt - the child feels responsible for the parent’s death
• Anger - this may be directed at the parent who died or a person who the child
believes caused the death
• Sadness - this is a normal and natural reaction to the death of a parent
Effects on Other People
In addition to the psychosocial effects of HIV/AIDS on children, there are also
effects on their carers (7.1). Adult carers may experience the feelings described
above. Children with HIV (3.2) may be particularly vulnerable to psychosocial
problems because of the additional stresses they face.
*
55
*
5.1.1 Grief and Bereavement
This section looks at issues relating to the grief and bereavement that children
experience, particularly when a parent dies. This is one of the mam
of circumstances.
Key points regarding grief and bereavement in children are.
1. Grief is the emotional response/feelings to an event that affects a person,
usually the loss of a person, thing or idea. Grief is a normal emotional
response to loss.
Children may experience a wide range of feelings as part of their grief These
include anxiety, fear and guilt. Initially, they may not accept or understand the
permanence of the loss. The feelings involved with grief may cause physical
2
problems for the child, such as feeling physical pain.
3. The ways children respond to loss and express their grief varies depending
on age.
4
There are many ways of assisting a child who is grieving. These need to be
appropriate for the age of the child.
Accompanying a Grieving Child
An adult who seeks to accompany a child through their grief needs to have
understood the way they feel themselves about grief and loss iri their own lives.
They need to be able to listen and speak to children in a way which is
appropriate for the age of the child. It is helpful for children to be able to talk
about the loss they have experienced. This will involve talking about death in
situations where a parent has died. Children should be allowed to express
emotions in these situations. Creative media, such as drawing, writing, telling
stories, games, drama, music and sports are all useful ways of expressing
feelings. Children may be better able to deal with their grief if they are prepared
for the death of their parent and if they are allowed to participate in rituals related
to death, such as funerals.
56
5.1.2 Resiliency
This section looks at issues relating to resiliency in children. Other sections look
at the psychosocial effects of HIV/AIDS (5.1) on children and the specific issue
of grief and bereavement (5.1.1).
Key points regarding resiliency in children:
1. Resiliency is the ability to cope with adversity. Children are naturally
extremely resilient and able to cope with very difficult circumstances.
2. Resilient children have the ability to understand an adverse event. They
believe they can cope because they have-some control over what happens.
They are able to give deeper meaning to the adverse event.
3. Resiliency comes from what the child has, who the child is and what the child
can do. The first of these is called external resources. The second and third
are internal resources.
4. It is possible to build resiliency in children in a number of different ways.
These either increase a child’s internal or external resources.
5. Key places where a child develops resiliency are in the family and at school
(4.2.3).
What is Resiliency?
Resiliency has been described as...
...the human capacity to face, overcome and be strengthened by or even
transformed by the adversities of life
... the universal capacity which allows a person, group or community to prevent,
minimize or overcome the damaging effects of adversity
... the ability to bounce back
... the ability to cope with life’s adversities
In many ways, it is the opposite of vulnerable. Vulnerable children are less able
to cope with problems they face in life. Resilient children are more able to cope.
Resilient children understand adverse events. They believe they can cope
because they have some control over what happens. They are able to give
deeper meaning to the adverse event.
Where does Resiliency Come From?
57
Resiliency comes from a child’s external and internal resources. Their external
resources consist of what they have. Their internal resources consist of who they
are and what they can do.
A child has:
• People that they trust.
• Structures and boundaries for their safety.
• People who set examples of how to behave. These are called role models.
• Encouragement to do things on their own. This is called being autonomous.
• Access to health (3.1.2), education (4.2.1) and social welfare services.
A child has a sense of who they are from how they are treated by other people. A
child is more likely to be resilient if they:
• See themselves as lovable and appealing.
• Are able to do kind things for others and show concern.
• Are proud of themselves.
• Are able to take responsibility for what they do.
• Are filled with hope, faith and trust.
A child is more likely to be resilient if they can:
• Communicate.
• Solve problems.
• Manage feelings and impulses.
• Understand how other people are feeling.
• Establish trusting relationships.
Building Resiliency
Steps can be taken which actively build a child’s resiliency. This is done by
increasing the internal and external resources available to them. This may
involve:
• Providing a safe, nurturing environment
• Spending time listening to and playing with the child
• Teaching a child how to communicate
• Allowing a child to make mistakes
• Involving the child in day to day activities and routines
• Praying with the child
• Trusting and valuing the child
• Using experiential learning in schools
58
The key places where children develop resiliency are in the family and at school
(4 2 3).
59
Y
5.2 Psychosocial Responses
This section looks at responses which can be taken to provide psychosocial
support (5) to orphans and vulnerable children. Other sections look in detail at
counseling (5 2.1), succession planning (5 2.2), training in psychosocial
support (5.2.3) and examples of psychosocial responses (5 2.4).
Key principles in responding to the psychosocial needs of orphans and
vulnerable children are:
1. All responses should be guided by the UN Convention on the Rights of the
Child (8).
2. All responses should treat all children equally without discrimination (8.2).
3. Communications with children should be based on openness and truth.
4. Children need to be prepared for the death of a parent. This helps them
understand what is happening. This means they can then cope better with
grief (5.1.1) and loss.
5. Children are individuals. They respond differently and have individual
psychosocial needs.
6. Early responses can prevent more serious problems occurring later.
7. Children should be allowed to participate (8.1) in decisions which affect their
future.
8. Care of children is best provided in families and communities. Institutions
(7.3.3) are very poor at meeting the psychosocial needs of children.
9. Responses need to focus on families as well as on individual children.
10. The community is an essential source of psychosocial support, Community
members need to be involved in any response.
11. Monitoring of programmes is needed to see what works best. Research is
also needed into the impact of HIV/AIDS on children and how children cope.
12. Responses need to focus on all children’s needs, not only the physical. Such
programmes are called holistic.
60
5.2.1 Counselling
This section looks at counselling orphans and vulnerable children. General
principles to guide psychosocial responses (5.2) for these children are
contained in another section. Other sections look in detail at succession
planning (5.2.2), training in psychosocial support (5.2.3) and examples of
psychosocial responses (5.2.4).
Key points about counselling children are:
1. The basic principles of counselling are the same as for counselling an adult.
8).
2. Counselling may be provided to children individually or as part of family
counseling. Common situations which mean children need counseling include
HIV testing, disclosure of HIV test results, death of a family member and
sexual abuse (8.3).
3. Counselling a child requires a relationship to be established between the child
and the counsellor. This is called ‘joining’. Methods to do this depend on the
age of the child.
4. Counselling children requires skills in talking and listening to children.
5. There are many tools which can be used to help communicate with children.
These include drawing, telling stories, play and drama.
Principles of Counselling
Counselling aims to help people cope better with situations they are facing. This
is true for counselling children too. This involves helping the child to cope with
their emotions and feelings and to help them make positive choices and
decisions. Doing this involves:
• Establishing a relationship with the child
• Helping the child tell their story
• Listening carefully
• Providing correct information
• Helping the child make informed decisions
• Helping the child recognise and build on their strengths
• Helping the child develop a positive attitude to life
It does not involve:
• Making decisions for the child
61
. Judging, interrogating. Oianrrng. preaching, lecturing or arguing
. Making promises that you can not keep
• Imposing beliefs on a child
Types of Counselling
Counselling may be provided
cmJassart of'?family. This
Seco"9"sel»ng is a"foZf'group counselling. Particular situations in which a
child may need counseling include.
: £S*^*ES"^***’
else the resort of a test is cafed “ » ”e "0 decjde if they are
feTrnS X*:he7eS "he, do so. the, need to decide bow
Counselling Skills
If an adult wishes to counsel a child they' hrst need to ed on the age of
with the child. This is
used w’th adults For example, for
^'un^^mS aS'“X InvOve getting on the hour Io play a game
that they like.
ide telling stories, drawing, drama and games.
Other Issues
Adults providing counselling for children nee^M be we o theown fe
towards issues which might come up m co sedl ng a ch
should be aware of their own ^ehefs o cu«u e. ba
be
of
They should avoid imposing^these on the c^
(0 (he child in a „ay
rules regarding confidenti w
counselling may reveal issues which
S2S "• ?SrXs?i"ed to act on behalf of the chi.d on some of
• mese issues. This is a form of localadvocacy (2.2.1).
62
5.2.2 Succession Planning
This section looks at the issue of succession planning. Succession planning is
planning for what will happen to children after their parents have died. Other
sections look in detail at counselling (5.2.1), training in psychosocial support
(5.2.3) and examples of psychosocial responses (5.2.4).
Key points about succession planning are:
1. There are many problems when a parent dies. These are worse if there has
been no planning.
2. There are many reasons why succession planning does not happen in
developing countries.
3. Responses which focus on encouraging succession planning use a variety of
methods, including the use of memory books and boxes.
4. Benefits of succession planning projects include increased appointment of
guardians, improved disclosure of positive HIV test results to children and
increased use of wills.
Problems of Poor Planning
There are many problems when a parent dies. These are worse if there has been
no planning. These problems include:
• Children not understanding what has happened.
• Adults being unclear as to who will care for the children and act as their
guardian
• Property being taken by relatives and others
Barriers to Succession Planning
There are many reasons why succession planning does not happen in
developing countries. For example, wills can be a key tool in this planning.
However, people rarely write wills in some developing countries. Reasons for this
include:
• Belief that writing wills and preparing for death can cause death.
• The tradition that property is only distributed after death by senior people
within the extended family.
63
• The tradition thSt women and young children
can not inherit property
• The tradition that wills are verbal not written.
. Limited knowledge and enforcement of laws.
• Limited literacy.
. Limited experience with legal issues among NGOs in rural areas
Responses to Encourage Succession Planning
Projects may seek to encourage succession planning in
a number of different
ways, including:
. counselling (5.2.1) HIV positive parents regardmg telling their children about
their test results.
• Creating memory books or boxes. These consisHjf a book o^ specjfic events
"^“S:i&-e*d^nS.TSwmd^
• respo^sib^lUies^f a^arem for^cfUMd the'pamnbs'no l^nge^ab^to do this.
• Training of guardians.
. Education on legal matters including practical support to write wills.
• Assistance with school fees and supplies.
. Training in ways of generating income (6.1) and funds to get activities
started.
needs of AIDS-affected children. This forms part
. Community sensitization on
oftheactivities described under local advocacy (2.2.1).
Benefits
Projects which promote succession planning have had several benefits. These
include:
• An increase in the number of guardians a
ppointed before a parent dies
64
• An increase in the number of parents who tell their children the results of their
HIV test. This is particularly true where children are over the age of 12 years.
• An increase in the number of wills written. However, in a project in Uganda
the number of people who wrote wills remained very low, although it rose
considerably from the level when the project started.
Experience has shown that a project has benefits beyond the area in which it
operates. This is because people within the project area share the benefits with
those outside the area.
65
572 3 Training in Psychosocial Support
in detail at counselling (5.2.1), succession planning 5.2.3) and examp------psychosocial responses (5.2.4).
Key points about training in this area are:
1
Training in providing psychosocial support is needed because Psych°^Cial
area.
leaders.
3. Training in this area is best provided using participatory learning methods.
Training Content
The areas which need to be covered in such a training course include:
• Why psychosocial support is needed.
• Different meanings of what it means to be a child.
• How children experience .grief (5.1.1).
. Imoortant ideas and words used when describing psychosocial support.
These include risk, vulnerability, stress, trauma, coping and resilience
(5.1.2).
. Responses and the principles (5.2) underlying them.
• Facilitation of learning.
• Monitoring and evaluation (2.3.1).
66
5.2.4 Examples of Psychosocial Responses
This section presents examples of projects which are responding to the
psychosocial needs (5.2) or orphans and vulnerable children. Other sections
look in more detail at issues of counselling (5.2.1), succession planning
(5.2.2) and training in psychosocial support (5.2.3). They are arranged by
alphabetical order of name by which the project is commonly known. Another
section has examples of projects working with orphans and vulnerable
children (1.3.1) in other ways.
A variety of documents are included. They are of two main types:
• Project descriptions are used to explain what the project does and to
promote its work. They may be written by someone from within the project or
outside. They may include some analysis.
• Reports of evaluations/reviews are usually longer and more detailed
documents. They are usually written by someone from outside the project and
include considerable analysis, including a review of project strengths and
weaknesses.
There are links to websites which give more detail of the work of particular
projects or organisations.
67
*
6 Economic Strengthening
This section looks at ways in which the economic position of orphans and
vulnerable children and their families can be strengthened. Details of specific
responses (6.1) are presented in another section. Children are extremely
resilient (5.1.2). They are able to cope with a wide range of difficult
circumstances. However, in some situations, these efforts to cope may produce
problems. Some of the problems (6.2) which may occur as a result of efforts to
cope with the economic impact of HIV/AIDS are considered in another section.
The key point underlying the need for responses focused on economic
strengthening (6.1) of orphans and vulnerable children is that HIV/AIDS
increases poverty. It does this at several levels:
• National
• Community
• Private Sector
• Family
National
HIV/AIDS increases poverty at national level. This is seen in falling gross
domestic product (GDP) and slower rises in human development index (HDI).
Community
HIV/AIDS fuels community poverty in different ways. It increases community
expenses, for example on contributing to funeral costs. These and other
community mechanisms which support families at times of difficult are called
‘community safety nets’. These are being placed under strain by HIV/AIDS.
HIV/AIDS is also causing other social changes. For example, illness and death of
teachers and health workers is reducing access to these services. In addition,
HIV/AIDS may be reducing the number of people who are available for wage
labour. HIV/AIDS may also reduce the number of employers looking for this kind
of worker.
Private Sector
HIV/AIDS is affecting private companies in a number of ways. It is increasing
their costs and reducing their profitability. An example of increased costs
includes the amount paid for funeral costs. The rate of absenteeism is high.
Costs of training new staff have increased overall costs.
68
Family
HIV/AIDS affects the economic situation of children (1.2.1) in many ways.
These ways include:
• Reducing income.
• Increasing family size. As the extended family absorbs more orphans, the
size of family increases. This increases the financial burden on the family.
• Increasing costs, for example of medicines and funerals
• Sale of assets.
There are three general ways in which families try to respond to the economic
trauma of death of a parent. First, they seek to respond in a way which is purely
reversible. Secondly, they use methods which are more difficult to reverse, for
example sale of assets. Finally, their actions become irreversible. This is termed
destitution.
U
69
6.7 Economic Responses
9
This section looks at specific responses which can be used to improve the
economic situation (6) of orphans and vulnerable children. Other sections look
in more detail at skills and vocational training (6.1 1), financial services for
the very poor (6.12), agriculture (6.1.3) and specific examples of projects
(6.1.4).
The key points about responses to strengthen the economic situation of orphans
and vulnerable children are:
1. It is important to be clear of the purpose of any activity before it is started.
This means that the right tool can be used.
2. Some projects seek to strengthen household resources. This may be done
in preparation for or after a crisis. Financial services aimed at the very
poor (6.1.2) can be extremely useful in these situations.
3. Other projects seek to provide relief to households at times of crisis.
Financial services aimed at the very poor are not appropriate in this
situation. Community ‘safety nets’ are needed. These can be established
in a variety of ways including community fundraising, mobilisation of
savings and joint agricultural activities (6.1.3).
4
Providing financial services to the very poor requires special skills. It also
requires a business-like approach. For these reasons, AIDS NGOs are
often not able to run these services effectively. Partnerships with specialist
microfinance institutions are more likely to be effective.
Why are Economic Strengthening Activities Needed?
It may seem obvious that such activities are needed because of the extreme
poverty faced by many orphans and vulnerable children, their families and their
communities. However, there are several reasons why such activities are
needed. It is important to be clear about the purpose of a particular activity so
that appropriate tools can be used. Reasons include.
• To strengthen the economic resources of a household. This may be needed
after a crisis or to prepare for a crisis that might occur. This is called
‘emergency preparedness’. Financial services aimed at the very poor
(6.1.2) can be extremely helpful in these situations.
. To provide relief to the most vulnerable households at times of crisis.
Financial services are not appropriate in this situation. This is because these
70
families are focused only on survival needs. They would not be able to use a
loan, for example, for business services. Community ‘safety nets’ are needed.
• To assist communities to create funds which can be used as ‘safety nets’ for
individuals at times of crisis. NGOs often try to establish group-run income
generating activities for this purpose. These rarely succeed. More effective
approaches are community fundraising and group saving schemes.
Communal agriculture activities (6.1.3) may work, particularly where these
have existed traditionally.
AIDS NGOs and Financial Services for the Very Poor
It has proved very difficult for AIDS NGOs to run financial services for the very
poor (6.1.2). Reasons for this include:
• AIDS NGOs are mostly involved in social projects. These have very different
aims and approaches from projects which provide financial services, which
are based on business principles.
• The confusion which occurs if organisations give money or goods to people
as grants and then try to introduce loans.
• The different skills which are required for social projects and financial
services.
• Group-based income generating activities favoured by AIDS NGOs are rarely
effective.
AIDS NGOs do have a useful role in activities which strengthen the economic
situation of orphans and vulnerable children. This may include supporting
community savings schemes, providing training and encouraging activities which
build community solidarity as this is essential if community safety nets’ are to
work effectively. However, AIDS NGOs that wish to introduce financial services
for the poor may wish to do this in partnership with an organisation with expertise
in this area.
71
>
a.1.1
Skills and Vocational Training
=H=“5~is'--—®bsss
of various projects (6.1 4)
■y points about skills and vocational training are.
The ke’
<
1
,opm,de
pj^pare^hTdm^and your^peop^lo^work, thTtramTng'musTbe0 aVpropriate
for the market needs in the local area.
■ sxsssss-s"-"
4. NGOs need Io assess carefully whether pTOj
mayPbe better
expertise in this area.
Project Examples
There are many examples °< projMteJj^raWe'chMrem In many cases,
"Xn-ry, catering, ah and design, adult literacy
and computer skills.
Purpose of Training
s«s training many be
it difficult to assess the success of the project.
72
Can AIDS NGOs Provide this Training?
AIDS NGOs are often very skilled at providing practical, participatory training
which is very appropriate in this setting. However, they may lack the technical
skills needed. This may result in people completing training without being able to
produce quality products in the chosen field. In addition, AIDS NGOs often offer
vocational training without assessing local markets. If such training is aimed at
providing livelihoods for orphans and vulnerable children, it is essential that they
either gain employment or can operate a small business on completing the
course. This will only be possible if there is a gap in the market for the skills they
have. In addition, to operate a small business they will need essential business
skills. Vocational courses offered by AIDS NGOs may be lacking in this area. In
addition, vocational training courses may be offered by AIDS NGOs but may not
be their highest priority. This may mean they do not always get the attention they
require.
Before starting courses of this nature, it may be worth asking the following
questions:
• Are the skills being developed in this course needed? Are there other skills
that are needed more?
• Will the training be of a high technical standard?
• Will people who complete the course be able to get jobs or run their own
businesses?
• Will the course give them all the skills they need? (This may include ‘how to
apply for a job’ or ‘how to run a small business’.)
• Does the NGO have the skills to run this kind of training well?
• Is this training a priority to the NGO? Is it part of their mission?
• Are there other organizations who have more skills in this area who the AIDS
NGO could work with?
73
6.1*2 Financial Services for the Very Poor
:a;jas:F‘sx;"X£a^
projects (6.1 4).
The key points about providing financial services for the very poor are:
people are able to run small, informal businesses and to repay loans with
interest.
2. A wide range of terms are used to describe these semces One of the
commonest is ‘microfinance’. Although this is often seen as mainly the
provision of small loans (‘microcredit’), it also includes activities which
promote saving.
3
Providing financial services to the very poor requires special
mouires a business-like approach. For these reasons, AIDS NGOs are often
not able to run these services effectively. Partnerships with specialist
microfinance institutions are more likely to be effective.
4
There are several questions which may need to be asked before starting to
X mlcXnoeLrvfces. Checklists can be useful for this purpose.
Features of Financial Services for the Very Poor
They are sometimes called •microenterprises' or 'income-generating actmt
financial shocks.
SaViTS|andZ^Sa^iKjSXS«”^cUlar.
or‘MFIs’.
74
One of the key activities of MFIs has been the provision of small loans to poor
people (‘microcredit’). MFIs charge interest on these loans. Interest rates are
often higher than market rates. MFIs require ‘security’ on such loans. However,
the types of security they will accept are quite varied. These include physical
property, such as goats and chickens and monies saved. Security may also be
provided by a group for loans to individual members. MFIs focus very strongly on
ensuring high rates of loan repayment. They have incentives to ensure loans are
repaid in full and on time. They have penalties for late payment.
Defining Terms
It is sometimes confusing reading documents about financial services for the very
poor because of the number of different terms used. The most commonly used
term is ‘microfinance’. This has been defined .as ‘financial services for the very
poor over the long-term through the establishment of self-sustaining indigenous
institutions’. Other terms include:
• Microenterprise Development - This includes microfinance and activities to
support business development. This includes training in running a business
and establishing market linkages.
• Microenterprises - These are small, informal businesses. They may be
operated by an individual or a group. They are also sometimes called income
generating activities.
• Income-generating activities - In the broadest sense, these are the same
as microenterprises. However, amongst NGOs the term is widely used for
activities which are aimed to increase the income of the organisation’s target
group. These activities may be run by individuals or, more commonly, by
groups. Such group-based income-generating activities are rarely successful.
Reasons include failure to clearly define objectives, lack of business skills,
lack of market research, insufficient client base and problems of running
income-generating activities as a group. Also, these activities are often
targeted at people who are experiencing a financial crisis. This is an
inappropriate approach.
• Microfinance - This has been defined above. These financial services have
two main elements. These are savings and provision of small loans. Savings
may be voluntary or compulsory. Compulsory saving means that people have
to save a fixed amount per month to be part of a scheme. Some microfinance
institutions also offer insurance services. These may provide money to clients
in case of death or illness. They may also repay a loan if a person fails to pay
the loan back.
*
75
• Microcredit - This is the credit element of microfinance only, that is, it does
not include savings. Some documents refer to this element alone as
microfinance. Level of loans vary from $50 to $50 000.
• Rotating Savings and Credit Associations - These are community groups
which encourage group members to save regularly. Funds generated through
saving may then be loaned to individual members. NGOs often encourage the
formation of these groups. Although they make credit available within the
group, this does not involve taking loans from microcredit associations.
Principles
Experience of providing financial services to the very poor has resulted in a
number of key principles being identified. These are:
• Microfinance is not a universal solution in all settings.
• Microfinance will only work in areas where there is sufficient cash-based,
market activity. This means that it may not work in some areas, where people
live on what they grow and buy very little.
• Successful microfinance institutions run on business principles. They do not
mix grants and loans. They expect loans to be repaid. AIDS NGOs are not
good at doing this work. However, they can be involved through partnerships
with microfinance institutions.
• Microfinance requires a large client base. This means that it will rarely work if
it is limited to the clients of a particular NGO, for example, people living with
HIV/AIDS. It is better to offer these services to all people in a community. In
areas with a high prevalence of HIV, this will mean that people with HIV are
involved.
• People who are running microenterprises require basic business skills. For
example, they should be able to calculate the price to charge for goods they
produce. Training may be required. This is part of microenterprise
development.
• Group borrowing for group projects rarely succeeds.
• Lending for production of agricultural crops is very risky. Crops may fail or be
eaten rather than sold. Many communities have previous experience which
raises expectations that funds supplied for crops are grants that do not need
to be repaid.
Checklist
76
It may be helpful to ask the following questions before starting to offer financial
services in an area:
•
Is the area’s cash economy sufficient to support microcredit?
•
Is the area stable? Wars or natural disaster increase the risk of loans not
being repaid.
•
Does the area have enough physical resources and access to market?
•
Can all the things needed for the microenterprise be obtained easily?
•
Are there enough clients? (600 has been suggested as a minimum.)
•
Does local culture and tradition support this kind of activity, particularly by
women?
•
Can people who will be clients travel to market and for other reasons as
needed?
•
Can microfinance staff live there? Could they get to a bank easily? Would
they be accepted by the community? Would a man be accepted to work with
female clients?
•
What else is currently happening for poor people in the area?
•
Does the local leadership support the introduction of microfinance activities?
Will they support measures to pursue bad debts?
•
Are there sufficient community and household ‘safety nets’? These are
important to help people with loan repayments in case of unforeseen
problems.
•
Are potential clients able to meet their survival needs? If not, there is a risk of
loans being used for these.
•
Is sufficient labour available for the planned activities? Will this be the case if
the key person is ill?
•
Do the clients have sufficient skills to run a small business?
• Are clients clear of the difference between loans and gifts?
77
6.1.3 Agriculture
This section looks at issues relating to agriculture and orPhfi^
ch dren/. Another section looks in general at responds (6 T}%n
to improve the economic situation of orphans and vulnerable chi'dren. Other
sectons look in more detail at skills and vocational tra.mng^^(6.1/'
services for the very poor (6.1.2) and speciftom^^
(6-1 -4).
The key points about agriculture and orphans and vulnerable children are:
1. HIV/AIDS is having serious effects on agriculture in severely-affectedI areas,
increased reliance on subsistence
These effects include loss of cash crops,
farming and sale of assets.
2. Responses which prevent or reverse these changes can have significant
economic benefits for households.
3. Ministries of Agriculture have a key role in supporting such responses.
Effects of HIV/AIDS on Agriculture
HIV/AIDS is having serious effects on agriculture in severely-affected area^
Families affected by HIV/AIDS commonly switch their agricultural efforts a y
X' :"ash crops. TPey focus an their efforts on pro.ucrog c^
to meet short-term economic needs by selling agricultural assets, such as
livestock and farming tools.
Agricultural Responses to HIV/AIDS
These changes may enable a family to survive. However, they push the family
them when they have happened can strengthen families economic situatio .
Ministries of Agriculture
<or
this include:
. Failure to include Ministries of Agriculture in National AIDS Committees.
78
• Efforts by Ministries of Health to involve Ministry of Agriculture staff as
extension health workers.
• The widespread view within Ministries of Agriculture that HIV/AIDS is a health
issue.
However, these views are changing. This is because HIV/AIDS has affected
Ministry of Agriculture staff directly and has also disrupted Ministry of Agriculture
activities. Ministries of Agriculture are having to adjust to environments which
have been severely affected by HIV/AIDS. For example, HIV/AIDS has reduced
the availability and quality of agricultural labour.
G
79
6.1.4 Examples of Economic Strengthening Projects
I?'<6 '
agriculture (6.1.3).
KSbin the projeot or outside. Tite, M include some analysis.
80
6.2 Problems of Economic Responses
This section looks at problems which orphans and vulnerable children may face
because of responses (6.1) they make to cope with the economic situation (6)
they face. Other sections look in more detail at the specific problems of child
labour (6 2.1) and economic and sexual exploitation (6.2.2).
HIV/AIDS affects the economic position of children and their families. Parental
illness and death reduces family income. Families spend more on health care
(3). These changes make children and their families poorer. Children and their
families respond to these changes in a number of ways. Some of these ways
help to meet immediate, survival needs, such as for food but increase
vulnerability in the long-term. Children without adult care are particularly affected.
Examples of responses which increase children’s long-term vulnerability include:
• Change in farming practices (6.1.3). These include the shift away from cash
crops and sale of farm-related assets.
• Removal of children from school (4) to save money.
• Involvement of children in child labour (6.2.1).
• Economic and sexual exploitation of children (6.2.2).
• Children who seek to live and earn a living on the street (7.2.3).
8!
*
6.2.1 Child Labour
issues of economic and sexual exploitation (6.2. ).
Key points about child labour are.
are done almost exclusively by children.
The extent to which children are expected to work appears to be
2
vulnerable to being infected with HIV.
3. Some documents distinguish between
child labour, which harms the child
and child work, which does not.
4.
Children carry out a wide-variety of work. Working children are vulnerable
and abuse. However, there are atso benefits to chrtdren
from working.
Worst forms of child labour include prostitution, slavery, trafficking of
5.
children, debt bondage and forced labour.
6. Effective responses will seek to empower children and to protect them
from abuse and exploitation.
Child Work and Child Labour
exclusively by children.
82
Much of the focus on the problems of child labour has been on paid work.
However, this may not be helpful because unpaid child labour may harm the
child. In fact, unpaid child labour may be more exploitative than paid labour.
HIV/AIDS and Child Labour
Until recently, there had been little direct research into the linkages between child
labour and HIV/AIDS. However, this has been studied intensively in several
countries in recent years. These studies show that the economic effects of
HIV/AIDS are resulting in more children working. This is particularly true of
children who have no adult to care for them. Other factors, such as poverty and
disasters also increase child labour. Working children are also more vulnerable to
contracting HIV infection.
Types of Child Labour
Children work in a wide variety of different areas. These include:
• Providing care within a family, for example to a sick adult relative.
• Domestic work - This may be paid or unpaid and provided wither to a relative
or non-relative. This is sometimes referred to as a hidden form of child labour.
This is because it is not easily visible and is rarely covered by campaigns on
child labour. Most of the children involved in domestic work are girls.
• Different forms of agriculture (6.1.3) - including both commercial and
subsistence farming.
• Selling items on the street (7.2.3).
• Transportation of goods.
• Work in warehouses and factories.
• Work in the fishing industry.
• Mining.
• Work in the military.
• Selling sex. This may involve very young children, for example from the age
of 9 years.
Some forms of child labour may not always be harmful to a child, such as
domestic work or agriculture. Whether or not harm occurs will depend on the
83
Harmful Effects of Child Labour
many harmful effects of child labour. These include:
There are
. Low pay. Children are often P^^^^XwTgelXre'fl^
example they may only receive one’ ^a
wages This is
KoaT7eeS'Xad.^^oXes competition for jobs directly and indirectly by
enabling more women to work.
. Long hours. Some children are expected to work excessive hours, for
example, up to 12-16 hours per day.
work they are doing.
Physical harm. Working children may experience physical barm in a number
of ways. These
include:
increased
risk of accidents - children ." unregulated
o
o
EsS-SSESapX;..
street mt 3) are also at risk of physical violence from police
o
o
o
-
Harmful effects of pesticides.
. Sexual abuse. This in eludes rape^ ^®<?^"t^udelU "pg study inKenya, one
” -"——bee"
sexually abused.
. Extreme forms of abuse and exploitatiom These include prostitution,
slavery, trafficking, debt bondage and forced labour.
|„ general, girls are more vulnerable to the harmful effects of child labour than
boys.
Responses to Child Labour
84
Many of the responses to child labour have focused on introducing laws to make
child labour illegal. Sanctions have then sometimes been applied to companies
which break those laws. However, there are problems with this approach. These
problems include:
• Failing to clearly distinguish between harmful and non-harmful forms of child
labour.
• Failing to recognise the benefits to children and their families of working.
These benefits include:
o The financial contribution made by the child to individual and family
livelihoods. These can be essential for survival.
o Learning important skills for living and earning.
o Improving education opportunities. This may be by making funds
available or by working in a place where education is provided.
o The pride and self-esteem felt by children because of the work they
do.
• Failing to recognise the harmful effects of children not working, particularly in
situations of extreme poverty.
• Rules and regulations are usually only able to be enforced in formal
employment. This forces children to work in informal, unregulated work where
they are more vulnerable. For example, children are not allowed to work in
the formal mining sector. However, many children work in informal mines in
appalling conditions.
• Laws which prevent children from working can be used by people in authority,
such as the police, to harass and physically assault children who are working.
Consequently, it may be more effective to work in ways which recognise that
children do work in most societies and that this is an essential survival
mechanism in situations of poverty. Actions could then focus on:
• Targeting the most abusive and exploitative forms of child labour, such as
child prostitution.
• Training children and finding other ways of protecting them from risk.
• Finding new ways of educating children who are working other than traditional
schools.
• Supporting working children to speak and act for themselves through the
formation of their own organisations and movements.
85
6.2.2 Ecbnomic and Sexual Exploitation of Children
This section tooKs at the issue
Another situation looks in detail at issues of cMdlabour (6 2 1).
Key points about economic and social exploitation of children are:
Many forms of child labour (6.2.1) involve the econornic. exploitation of
1.
children. Some people regard all child labour as exp
Sexual exploitation of children involves sexual abuse of chUdren and payment
2.
of money to them or a third party.
of sexual exploitation include sex tourism, child prostitution, child
'■ — --r
3. Forms Oi
pornography, trafficking and early marriage.
■ ■ ) more vulnerable to sexual exploitation. These
4. Many factors make children
in^epoveny.
increasing urbanisation.
c°u",ries and
86
7 Living Environments
This section looks at the different environments in which orphans and vulnerable
children live. Other sections look in detail at who provides care (7.1) for these
children, particularly difficult situations (7.2) in which they might live and
alternatives to care (7.3) within the community/extended family.
Key points about the living environments for orphans and vulnerable children are:
1. Most orphans and vulnerable children in developing countries live in the local
community with their extended families.
2. The capacity of the extended family to cope is being severely tested by
HIV/AIDS. Signs of this include increasing numbers of children living and
working on the streets (7.2.3) and the emergence of child-headed
households (7.1.2).
The Extended Family
Most orphans and vulnerable children in developing countries live in the local
community with their extended families. The way in which this is done varies from
place to place. For example, in some places this is the responsibility of the
father’s family and in other places the mother’s. It may vary depending on precise
circumstances. In some situations, this care involves remarriage within the
extended family.
There are many reasons why children may be cared for by their extended family
rather than by their parents. Although parental illness and death is one of them,
others include parents working, particularly as migrant labourers.
Strains on the Extended Family
HIV/AIDS is placing an increasing strain on the extended family in many
communities. This is because:
• The number of children requiring care and support from the extended family
has increased.
• HIV/AIDS increases poverty. Poverty makes extended families less able to
cope with caring for additional children.
• The number of available adults to take on caring responsibilities has been
reduced through illness and death. Much of the burden of care has always
fallen on women. It is now particularly falling on the very young (7.1.2) and
the old (7.1.1).
87
Some people argue that extended famrly structures a«» not as strong as they
once were in man? communities. Reasons for this mclud
. increasing adoption of Western' lifestyles, including the nuclear' family
. The increasing number of people in developing countries living in cities.
. An increasing reliance on cash to buy things that are needed by the family.
cared'fcv outs^e ibe’XIXmi
on the street (7.2.3) and those living in child-headed househg—(
Issues about Living Environments
Particular issues about living environments are.
• Who provides care
environments?
(7.1) for orphans and vulnerable children in those
(7 9 1) prisons and detention centres (7.2.2), the str—(
situations of conflict (7.2.4).
arranae foMhe child to be cared for outside of the extended fam y. These
88
7.1 Carers
This section looks at issues relating to people who provide care for orphans and
vulnerable children. It looks at who these people are and examines, in particular,
the problems of stress and burnout. Other sections look, in general, at
environments in which children live (7) and in detail at issues facing older
carers (711) and child-headed households (7.1.2).
Key points about carers of orphans and vulnerable children are:
1. Most orphans and vulnerable children in developing countries are cared for by
family members in the local community. These family members include
surviving parents, grandparents (7.1.1), other adults and brothers/sisters
(7.1.2). These people are a child’s primary care givers.
2. Although men are often identified as a child’s formal guardian, the burden of
care falls mainly on women.
3. Primary care givers may receive support from a number of sources. These
include community-based volunteers (2.2.2), professional staff and
traditional healers.
4. Care givers may experience stress for a variety of reasons. In some
situations, this stress gradually builds up until a person can no longer cope.
Their physical and mental health, personal relationships and standards of
care may all suffer. This is referred to as ‘burnout’.
Carers of Orphans and Vulnerable Children
Most orphans and vulnerable children in developing countries are cared for by
family members in the local community. These family members include surviving
parents, grandparents (7.1.1), other adults and brothers/sisters (7.1.2). These
people are a child’s primary care givers.
A study in Uganda showed that orphans received care from a surviving parent in
50% of situations. Other carers were grandparents (35%), aunts/uncles (11%)
and brothers/sisters (3%). Most of the brothers and sisters providing care were
aged over 18 years but there was one situation where care was being provided
by a child (7.1.2) under the age of 18 years.
Although many children are cared for by surviving parents, this is not
automatically the case when one parent dies. Reasons why this might not be the
case include:
*
89
Cultural practices which lead to children being ‘inherited by one side of the
family (oftemthe father’s) rather than by the surviving parent (usually the
mother).
• The surviving parent remarrying and the new partner being unwilling to take
on responsibility for the children. This is strongly influenced by cultural norms
and practices.
• Better economic prospects for the child with the extended family.
• The surviving parent being unable to care for the children. A common reason
for this relates to the parent’s need to work.
Although men are often identified as a child’s formal guardian, the burden of care
falls mainly on women.
Primary care givers may receive support from a number of sources. These
include community-based volunteers (2.2.2), professional staff and traditional
healers.
Stress and Burnout
Care givers may experience stress for a variety of reasons. In some situations,
this stress gradually builds up until a person can no longer cope. Their physical
and mental health, personal relationships and standards of care may all suffer.
This is referred to as ‘burnout’. Primary care givers may experience stress and
burnout, as well as volunteers and professional staff.
Signs of stress include:
• Physical symptoms, such as inability to sleep and bowel disturbances.
• Emotional problems including feelings of inadequacy, helplessness and guilt.
• Withdrawing from other people.
• Reduced quality of care.
• Worsening relationships with other people.
Stress is caused by a number of factors including:
• Poverty and its effects, including lack of resources to meet survival needs of
both the child and carer. This includes lack of food and medicines.
90
• Interpersonal and family conflict. This is common within families affected by
HIV/AIDS because the virus spreads mainly through sex. This often leads to
people being blamed for ‘bringing the virus into’ the family.
• Isolation and fear for the future.
• Excessive workload.
• Stigma and discrimination (8.2) relating to HIV/AIDS.
• Excessive personal involvement in issues relating to the child.
• Poor organizational arrangements. This applies particularly to secondary care
givers. Issues include lacking a voice in thB way things are done, inadequate
support and lack of clarity over roles.
Stress and burnout can be managed by developing personal coping mechanisms
and organisational strategies. Religious faith may be important as part of
personal coping mechanisms. Organisational strategies include:
• Recognising that caring is stressful and that stress and burnout are complex.
• Ways of dealing with problems that carers can not deal with.
• Finding ways of showing that carers are valued.
• Providing carers with training.
• Relieving poverty and ensuring that activities are reliably funded.
• Effective stress management measures including regular time off, realistic
workload, team meetings and participation in decision-making.
91
7.1.1 Older Carers
(7 1) and in detail at child-headed households (/
2).
Key points about older people and HIV/AIDS are:
?xrapss:r:nsxaK
Much of this burden falls on women.
2
. Their income is often
Poverty is the main problem facing most older carers
' declining because of age. Their caring responsibilities mean they have less
time available to generate income.
Older People and HIV/AIDS
this burden falls on women.
Poverty and Older Carers
Poverty is the main problem facing most older carers . Their income is often
declining because of age. Their caring responsibilities mean they have less time
available to generate income.
Other Issues
Other issues affecting older carers include:
• gaasssse&'ssssas“=.
fairly.
. Information about HIV/AIDS is rarely focused on older people.
. Research into HIV/AIDS and its effects often excludes older people.
92
7.1.2 Child-Headed Households
This section looks at issues relating to child-headed households. Other sections
look, in general, at issues facing carers (7.1) and in detail at issues facing older
carers (7.1.1).
Key points about child-headed households are:
1. A child-headed household is one which is led by a child under the age of 18.
This child takes on responsibilities usually carried out by parents, including
providing care to other children.
2. Child-headed households have been observed in parts of Africa which have
been badly affected by AIDS. They are a new thing in those areas. The main
cause of this change is the large number of young adults dying from AIDS.
3. Some documents state that child-headed households are evidence that the
extended family system is collapsing and failing to cope. Evidence shows that
most child-headed households receive support from their extended families.
Child-headed households are one way in which the extended family is
adapting to cope with problems produced by HIV/AIDS.
4. Child-headed households face a wide range of issues. The most pressing
relate to survival needs and poverty.
5. Child-headed households can be helped to cope more effectively with modest
levels of support. Effective support mechanisms include visits from
community volunteers, modest levels of material support and training in
effective parenting.
What are Child-Headed Households?
A child-headed household is one which is led by a child under the age of 18. This
child takes on responsibilities usually carried out by parents, including providing
care to other children. Children as young as 8 act as heads of such households.
The main event that leads to establishment of a child-headed household is the
death of both parents. However, in some cases, one or both parents are still
alive. Other events include parental illness or disability. In some cases, one or
both parents have left the family home for some reason. The term is usually
applied to households where the person heading it is not the parent. Although
there are many documents about teenage pregnancy, this does not appear to
have been identified as a factor in causing the establishment of child-headed
households.
93
In many cases, the child-h eaded hou^hold
Mt^bya relative,
another event such as, the death ot that care giver
resulted in a child-headed household being established.
te^ser^u.1 ^Th^ntay be
Child-headed heuseho.ds
due to higher cost of livmg in urban a ea5 and
d by adu|ts in urban
s*are ofte"re,er,ed
to as street children (7.2.3).
some cases, aduits do live withini households which are ob^eaded.^
Similarly, some authors identlfy,ado1®®is not the
headed once the primary caregiver reaches 18 years ot age.
Child-Headed Households and HIV/AIDS
Child-headed households have been obs®^®d inthpa gSafea^Most child-headed
badly affected by AIDS. They are a new th ng^n those ar<of
death ^no* "alwa'sTown but HIV/AiDS is likely to be the cause in most cases.
BSSSsasr-. ’ ofen vlsite'd^by thom0They0may'rVeecbivbd|h't®l'^l^Xc’bbt®e'^^^^'
"e
•
•
m SOIIIC iiiuauviw,
extended family. The older children
households.
various r.ascns ar, given lor ^ren
than with the extended larnily
is
««^d househ- ^ber
y
ref|ec, the wishes of the parent
94
household rather than to risk loss of the family home and other property. In
addition, children often wish to stay together. This is not always possible if care
of children is taken on by extended family members.
Issues faced by Child-Headed Households
Child-headed households face a wide range of issues. The most pressing relate
to survival needs and poverty. Children in child-headed households need to work
hard to care for each other and to earn a living. They may miss out on education
(4) and health care (3). They have to cope with grief (5.1.1), stigma and
discrimination (8.2) and may receive little support from the community.
Helpful Responses
Child-headed households can be helped to cope more effectively with modest
levels of support. Effective support mechanisms include visits from community
volunteers, modest levels of material support and training in effective parenting.
Training in effective parenting involves learning:
• Skills in caring for sick people.
• About growing-up, including issues relating to sex, drugs and alcohol.
• Household management.
• Nutrition and cooking.
• First Aid.
• About laws and human rights (8).
• How to deal with conflict in families.
• How to record memories.
• How to encourage children to play.
95
7.2 Children Living Outside of Family Care
■ ■ i are living outside the care of their
This section looks at situations where children
by H.WDS M£**«**»
s
C'"* "
another.
(7J) is pr0''ided by
However, some children live outside the care ot their extended tanrUy. These
%
include:
. Children living on commercial farms and at other workplaces (7.2.1).
. Children living in prisons and detention centres (7.2.2).
• Children living on the street (7.2.3).
. Children living in situations of conflict (7.2.4)
96
7.2.1 Commercial Farms and Other Workplaces
This section looks at the situation facing orphans and vulnerable children living
on commercial farms. The experience is based largely on the work of Farm
Orphans Support Trust (FOST) in Zimbabwe but lessons learned would be
relevant to other workplaces which involve workers living at the workplace.
Another section looks in general at issues facing children living outside of
family care (7.2). Other sections look in detail at children living in prisons
(7.2.2), on the street (7.2.3) and in situations of conflict (7.2.4).
Key points about orphans and vulnerable children living on commercial farms
are:
1. Much of the experience comes from Zimbabwe, in general, and the work
of Family Orphans Support Trust (POST), in particular.
2. The nature of the ‘community’ of workers living and working on
commercial farms makes children living there particularly vulnerable.
3. Orphans and vulnerable children on commercial farms face many of the
same problems faced by other vulnerable children. However, they rarely
have supportive contact with extended family members. This means they
often lack the family and community safety nets available to other
vulnerable children.
4. There are a range of appropriate responses which avoid the use of
institutions (7.3.3). These include the use of farm-based volunteers and
non-relative foster carers (7.3.1).
Communities of Farm Workers on Commercial Farms
There are many examples of forms of work which require large numbers of
people and require them to live and work at the same place. One example of this
which has been widely studied relates to commercial agriculture in Zimbabwe.
Communities of workers on commercial farms have certain characteristics.
These include:
• Lack of sense of community - workers on commercial farms lack a shared
sense of history and belonging which is seen in other communities. They
rarely have community structures for decision-making. This results in low
levels of social organization.
• Isolation - because of distance and poor communications. Consequently,
farm workers may be marginalized from political processes.
*
97
. High mobility - workers move from one farm to another.
. Lack of extended family structures - many workers originate from other
countries originally and have lost links with their extended family.
. Lack of personal identification documents - such as birth certificates
(8.4.1).
all features of farm
life.
. Poor access to facilities for recreation, heaffi (3.1.2) and education
(4.2.1).
Orphans and Vulnerable Children on Commercial Farms
Problems which affect orphans and vulnerable children on commercial farms
include:
. Food insecurity (3.1.1).
• Lack of access to education (4.2.1).
• The struggle to meet material needs.
• Lack of psychosocial support (5).
. Poor life skills (4.2.2) and knowledge.
• Abuse and exploitation (8.3).
. Lack of extended family network.
• Poor housing.
. Lack of secure tenure of housing. This means they do not own their house
and can be asked to leave by the farm owner.
• Lack of access to health care (3.1.2).
98
• Lack of birth certificates (8.4 I).
• Involvement in work (6.2.2).
Appropriate Responses
In general, responses aimed at orphans and vulnerable children are broadly
similar to responses in other settings. They are based on the same principles
(2.2). This means that establishing institutions (7.3.3) is almost never
appropriate. Because of the particular nature of communities on commercial
farms, new and imaginative responses may be needed. Examples include:
• Working constructively with the farm owner.
• Seeking to establish community development structures on farms, such as
farm development committees (FADCOs).
• Providing short-term material support to compensate for absent ‘safety nets’.
This may include provision of food and funds for school fees.
• Providing training in psychosocial support (5).
• Identifying and training volunteers from among farm workers. This may
include using existing people, such as farm health workers (FHWs).
• ‘Fostering’ children with non-related farm workers (7.3.1). There are often
cultural taboos regarding taking responsibility for unrelated children. However,
this can be overcome by regarding the children as household ‘guests’.
• Income-generating activities (6).
• Advocacy (2.2.1) at local and national levels.
• Succession planning (5.2.2) and other activities focused on preparing for
death.
99
7.2.2 Prisons and Detention Centres
This section looks at the situation
S"
prisons and detention
n° ® „ 2) otfier sections look in detail at
children living outside of family carg.(/Z).
.|n
children living on cpmmeixialfarms (7.2.1). on the street
situations of conflict (7.2.4).
Although a great dea, has beersX'6'’'
S23XSS may be mom> ^^age InhWI
aa*X. =: tXZ—- * - - more .ike,
to end up in prisons or detention centres.
Children In prison are particuiar, vulnerable Children may
environment for a number of reas ~
because of offences they
their mother is in pnson. 0,de^J'
j r^on are vulnerable to physical and
S^"a"tbere kilties to keep them separate trom adult
prisoners are inadequate.
100
7.2.3 The Street
This section looks at issues relating to children living on the street. Another
section looks in general at issues facing children living outside of family care
(7.2). Other sections look in detail at children living on commercial farms
(7.2.1), in prisons (7.2.2) and in situations of conflict (7.2.4).
Key points about ‘street children’ are:
•
They are defined by the United Nations as children for whom the street
has become their home and/or source of livelihood, and who are
inadequately protected or supervised by responsible adults.
•
They are mostly boys. Girls are more likely to become involved in
domestic work or selling sex.
•
There are ‘push’ and ‘pull’ factors which cause children to be on the street.
Parental death due to HIV/AIDS is an increasingly important ‘push’ factor.
•
Street children are vulnerable to many problems. They are particularly
vulnerable to HIV infection as a result of survival and commercial sex.
•
There are many examples of programmes which are working effectively
with street children. Key principles have been developed from that work.
Street Children: Who are They?
The United Nations defines street children as girls and boys for whom the street
has become their home and/or source of livelihood, and who are inadequately
protected or supervised by responsible adults. This is a broad definition. It
includes homeless children who live on the street. It also includes children who
earn their livelihood by working on the streets. It does not include children who
live on the street with their families.
The number of street children are increasing in many cities around the world.
They are mainly seen in cities and are said to be one feature of the increasing
number of people moving to cities from rural areas.
Most street children are boys. Girls are also affected by the same things that
cause boys to move to the streets. However, they are more likely to become
domestic workers or commercial sex workers. In many cases, both these kinds of
work amount to a type of slavery. Girls working as domestic workers are often
sexually abused. Girls living and working on the street are particularly vulnerable
to sexual abuse.
*
101
Koramangala
a rural area to the city and then
the street because they are unable to live e^ewherefind themselves living on t..- . movement can be categorised as push and pull
Reasons for such rural-urban
factors.
Factors which ■push’ children away from the rural areas include:
. Poverty and lack of economic opportunity.
• Rural underdevelopment.
. Hardships and uncertainties of subsistence farming.
live as child-headed households in rural areas.
Factors which pull children towards cities include:
• Improved job opportunities.
• Leisure and entertainment.
. Reports from peers of positive experiences.
• A sense of adventure.
Problems of the Street
Street children face a wide range of problems on
the street. These include.
. Work-related problems - iong hours, low pay and dangerous conditions.
• Poor diet.
. Lack of shelter - poor hygiene and overcrowding.
. poor access to healthcare (3.1.2) and education (4.2.J).
102
V2i5 ^>5
LSd^
• Harassment from the authorities, adults and other children. Street children are
often in conflict with the law. They risk arrest and imprisonment.
• Sexual abuse. They may engage in sexual activities for money or simply to
survive. They are vulnerable to sexually transmitted infections, including HIV.
• Substance use - including glue sniffing, illegal drugs and alcohol.
Appropriate Responses
Programmes which aim to work with street children should be focused on the
child’s ‘best interests’. This means starting working with them where they are and
not trying to force them to leave the streets. In some places, authorities have
introduced activities which are focused strongly on children leaving the street.
These are usually motivated by factors other than the best interest of the child,
such as civic/political pressure to ‘clean up’ the streets.
Appropriate activities may assist them to find alternatives to life on the street.
Equally, they may assist them to remain safe while on the street. Key features of
appropriate activities for children living on the street include:
• Establishing a sense of trust with the children. Many street children mistrust
adults, particularly those in authority. Overcoming this mistrust is essential for
an effective programme and for the children to be more integrated in the
community.
• Building skills which enable children to earn a living or enter the labour
market.
• Imaginative ways of providing education (4) and health care (3) for street
children.
• Advocating on behalf of street children with those in authority. This may be
done at national level. However, it is particularly needed at local level (2.2.1).
For example, programmes working with street children will need to engage
with police officers in the area to try to encourage a more supportive
approach to street children.
• Ensuring that street children participate (8.1) in design of programmes. They
should also participate in decisions which affect them.
• Reducing their vulnerability and risk to sexual abuse and its consequences.
• Working with families, the community and other organisations.
• Seeking to address the reasons why children move to the streets.
103
7.2.4 Situations of Conflict
This section looks at issues relating to
Another section looks in general a «
6v|ng „„ ^^sraal
9
Key points about children living in situations of conflict are.
Conflict and HW/AID5
.
■
XfabW through
"paX iXd if/danfaging families and communit.es that
protect and care for children.
.
conflict increases vulnerability to the spread of HN/AIOS.
•
^XhoXXore-XX-^^^^^
the spread of HIV/AIDS.
.
Efforts to provide^utionj (7.3.3).
rebuilding communities ana not ui
HIV/AIDS and Conflict - A Double Emergency
Conflict and HIV/AIDS have beer'
causing
they occur together, they mcreas
communities that protect and care
r MdXf tee v —X- man .00 000 children orphaned by
HIV/AIDS, 13 are affected by conflict.
War Spreads HIV
People living in areas
for this include:
affected by conflict are more
vulnerable to HIV. Reasons
• Community disintegration.
• Displacement of people.
*
. Destruction of services Including iffiglft CT and
confnct
SXSX.: — monitor the way....... ch HIV is
spreading are often not in place.
104
• Increase in sexual violence against women, including rape. Rape is used as a
weapon of war and is particularly common in refugee camps.
• Many women sell sex in order to survive in situations of conflict.
People living in refugee camps may be particularly vulnerable to the spread of
HIV. Social structures, norms and values may all be affected in camps.
Armed forces may contribute to the spread of HIV. They may encourage local
women to trade sex in exchange for protection. They may also engage in casual
and commercial sex in areas where they are based for prolonged periods.
Responses
Effective responses require training of armed forces and humanitarian staff in
how to deal more constructively with children and how to prevent the spread of
HIV/AIDS.
Efforts to provide care for children should focus on reuniting families and
rebuilding communities and not on establishing institutions (7.3.3).
*
105
7.3 A/ternates to Community Care in Extended Families
This section looks at alternate forms of care for *“en
^tended (amte (7). Other sect'O"5 “k(7 2) oih^sectons
a"d ESSMSDM
Stotaitot
care (7.3.3).
Key points about alternate forms of care are.
.
in many countries■ lJIV/Al°|'^X'nMVsTof th^sechildren are cared
for'by thelr'extetoed^amilies. This form of care needs to be snppor e
and promoted.
.
However, this is not avakable to all children. Some
children live outside of
family care (7.2).
allow the state to take over responsibly
state has legal responsibility for t^chilcLTh
nolXgXd
these forms of care.
In addition, the state often
tQ provjde care for the
community care are informal and
<*“ for the State °
"
’
'if poverty^ widespread
It will usually pay for care prov de
for fjriancjal reasOns. The state is
SS "matolal support to people providing care with.n the
extended family in the community.
r tArms used to describe various forms of alternative
larTsom: XsXms overiap. Commonly used terms include:
. Adoption -This involves a child being taken into the care
adoption is usua.ly only
106
applied where the people ‘adopting’ the child are not relatives. Once a child is
adopted, the state usually stops being financially responsible for that child.
• Fostering - This also involves a child being taken into the care of adults
other than their parents. It is usually a temporary arrangement and the state
retains financial responsibility for the child. It is a formal/legal arrangement
and usually involves non-related adults. In many cases, people foster large
numbers of children. These ‘foster homes’ are essentially small institutions.
• Residential Care - This term is used to apply to institutions (7.3.3) which
provide child care. Most of the children in these institutions are placed there
by the state. Institutions may be run directly by the state or by other
organisations. Many institutions are moving towards structures which try to
recreate family life as much as possible. -
*
107
Child with Another Family
7.3.1 Placement of a
care (7.3.3).
used .0 describe these situations. Comment, used terms
Various terms are
include:
some cases, the child may be
a„7proSems with this form
"ex’? XXen no other forms of care are avail a e.
Fostering - This also involves a
other than their parents. It is usuallyfOrmal/legal arrangement
X financial response yfor the * It isa
people fosteHayge
ruX’S XmTXe'X homes’ are essentia,., small
(7.3.3).
I08
7.3.3 Residential Care
This section looks at issues relating to residential or institutional care of children.
Other sections look, in general, at other alternatives to extended family care
(7.3) and in detail at placing children with other families (7.3.1).
Key points about residential care for children are:
• Residential care is an ineffective way of providing care for children. It is poor
at meeting their psychosocial needs (5) and prepares them poorly for adult
life. It is also extremely expensive and could never provide care for more than
a very small proportion of orphans and vulnerable children.
• Residential care has harmful effects on societies. It promotes stigma and
discrimination (8.2), consumes resources and undermines community
based care responses.
• Based on this evidence, many countries have agreed that no new child care
institutions should be built. However, there continues to be widespread public
and political support for these institutions.
• Child care institutions will continue to exist and operate for the foreseeable
future. They should be run to agreed standards to improve services provided
for children in their care.
• A few organisations are moving away from providing institutional care to
supporting community-based methods of care. These efforts need to be
encouraged and replicated.
The Problems with Residential Care
A great deal of evidence has been collected from around the world which shows
that residential/institutional care is an extremely poor way of providing care for
children. Problems of residential care include:
• It prepares children poorly for adult lives as it places little evidence on
teaching them skills they need.
• Children who grow up in institutions often fail to develop their own cultural
identity. They may feel alienated from their community. They often lack
networks of friends and relatives and may lack the social skills needed to
develop these. Adults who grew up in institutions form an ‘underclass’ in
some societies.
*
109
. cwren from -Wons often laoK interpersonal sKIHs. Some ma, rfeveiop
anti-social forms? of behaviour.
. msfltotions are
poor a. providing for cftildren's BSMChosoeialnoeds (5).
»
. CMdren in institutions are more vulnerable to pmimWaml^x^gb^
. institutions may P™™'® ^gS^SS^rewnd XmXd as a
“rS^eal-d beyond tbose In the .oca,
community may also promote stigma.
. The cost of providing care in institutions i®9|nstitutjons have been
SIXS“u-a?be, attract them which means that
fewer resources are available for other forms of care.
r
. Institutions undermine community --XSf"are “"addS. -Zs
Sa^XwZSre^.™^—
“mugb —on tifsuppoff afchfld may relieve the financial burden on
the family/community.
■ =====SSSthese children.
. Many institutions lack staff who are skilled in providing child care.
. Children rarely have the opportunity to Bartlcieate (8.1) in decisions that
affect them in residential care.
• Much residential care fails to meet the
the Rights of the Child (8).
requirements of the Conventionon
Why are there so many Institutions?
There is a great deai of evidence that Insfitutions a^e -
'"9
care for children. In developed countries many have ClOfs^g
^XXXCanZveHiZ. New institutions are being bulk. Reasons
for this include:
110
• The widespread belief that institutions are the best or only way to care for
children. An example of this would be India where this view is widely held.
• The desire in certain societies to control children and to prevent them from
being a nuisance. Many institutions set up for ‘street children’ are based
largely on this desire rather than the best interests of children.
• Moral and religious values. Many institutions are run by religious
organisations who seek to promote particular values and beliefs. These
beliefs may include the view that certain environments are not suitable for
raising children. An example of this is an institution aimed only at children of
commercial sex workers in India.
• Political and public support for child care institutions. Many institutions in
developing countries are supported by local political figures. This is because
they are seen as a worthy cause by the general public. In addition, the
general public in developed countries have similar views. This means that
child care institutions in developing countries are able to raise funds relatively
easily.
• Institutions may represent an ‘easy’ option for social workers. Administrative,
legal and financial issues may make it easier for a social worker to place a
vulnerable child in an institution rather than trying to support them in their
extended family or community.
• Cultural barriers to adoption and fostering (7.3.1). In many societies, there
are cultural beliefs which make it difficult for a family to adopt or foster a child
who is not related to them.
The Way Forward
Residential care is an inappropriate way of providing care for children. However,
some people argue that this should be available as a last resort for children
where no other form of care is available, particularly on a short-term basis. The
problem with this argument is that it allows institutions to remain. They will
continue to be magnets, attracting both children and resources.
The following principles are proposed:
1. No new child care institutions should be built. Current institutions should
not expand their residential facilities.
2. Institutional facilities should be adapted to provide services other than
residential care. These might include day care facilities and educational
services.
*
111
A
3. Guidelines and rules (or residential
be adopted b,
V
participate in all decisions which affect them.
*
independent living.
112
8. Children’s Rights
This section looks at issues relating to children’s rights, particularly in relation to
HIV/AIDS. Other sections look in detail at children’s participation (8.1), stigma
and discrimination (8.2), protection from abuse (8 3) and legal issues (8 4).
*
Key points about children’s rights are:
)
1. The UN Convention on the Rights of the Child (CRC) is the main
international document which defines children’s rights. Developed in 1990,
it has been adopted by every country in the world apart from the United
States and Somalia.
2. This convention has four main principles:
•
•
•
•
A child’s right to life, survival and development.
A child’s right to be treated equally. This means that no child should
be discriminated (8.2) against.
A child’s right to participate (8.1) in activities and decisions which
affect them.
All actions should be based on the ‘best interests’ of the child.
3. There are various ways in which the convention can be used to influence
activities in practice.
The Convention in Practice
The United Nations Convention on the Rights of the Child is one of the most
widely accepted international conventions. Almost all the countries of the world
have agreed to it. However, progress has been quite slow in putting it into
practice. Reasons for this include misunderstandings about the Convention,
which has been seen by some people as being ‘anti-family’ or simply about
allowing children to have their own way. Neither of these is true but these
misconceptions need to be addressed when seeking to increase awareness of
the Convention and what it means in practice. Poverty is a major barrier which
prevents implementation of the Convention. However, it can be used to guide
efforts aimed at promoting development and eliminating poverty. This will ensure
that children gain the maximum benefit from such actions.
In practice, the Convention can be used:
• As a framework for designing programmes.
• As a way of evaluating programmes and national strategies. For example, it is
possible to look at how practices in a particular country affect orphans and
vulnerable children and compare that with the provisions of the Convention.
113
. As a different way of looking at particular issues.
The last point is a sety
't"XTS’”'
examined in this ways include.
•KWXasXSSSS'SS
this term goes against the Convention.
•sssaESSB.
Convention.
. Issues of birth registration (8 4.1) and inheritance (8.4.2).
• Poverty and development.
. Access to health (3.1.2) and education (4.2.1).
• Access to information.
• Sexual exploitation and abuse (8.3).
• Child labour (6.2.2).
114
8.1 Participation
This section looks at issues relating to children’s participation. This is one of the
rights (8) described in the UN Convention on the Rights of the Child. Other
sections look in detail at stigma and discrimination (8.2), protection from
abuse (8.3) and legal issues (8.4).
Key points about children’s participation are:
4. There are many reasons why children should participate in activities which
affect them. These activities include those focused on HIV/AIDS.
5. In many societies, children’s voices are rarely heard. They have little
opportunity to participate. Adults often take decisions without talking to
them.
6. Programmes which aim to promote children’s participation will need to
face a number of issues raised by children’s participation.
7. Children may participate at different levels ranging from being given
information to full partnership. Some forms of ‘participation’, such as
‘tokenism’ and ‘decoration’ exploit children. They should be avoided.
8. Children may participate in a variety of different ways. There are many
tools which can be used to promote children’s participation.
Why Should Children Participate?
There are many reasons why children should actively participate in HIV/AIDS
programmes. These include:
• The right to participate is a basic human right (8). Children are entitled to
this. This right is contained in the UN Convention on the Rights of the Child.
• Children are the only ones who can describe issues from their perspective.
• Participation builds children’s self-esteem and confidence. It allows them to
develop important communication skills.
• Through participation, children learn to cooperate with adults and other
children.
• Programmes which allow children to participate are better programmes. For
example, they are often more responsive to the needs of children*
115
. Children’s participation raises public awareness of the needs of children
The Reality
Unfortunately, children rarely get the
ren tTparticipate, adults need
X^SS^XStor^iidren.
Children’s participation should not only be encouraged in HIV'«DS programmes,
but also in Xr settings including in the family and schools (4).
Issues Arising from Participation
There are various issues which may arise when children actively participate in
programmes. These are:
. Children may risk being identified ^Xa^X'iXLTorSX65'
Confidentiality must be
children. Careful consultation
that a child will be identified.
. Programmes need additional resour(^Xe^oUupport. They may require
children. Children may require additional leve
PP
training to provide needed skills and confidenc .
the long-term.
Levels of Participation
Children may experience different levels of participation. This has been
described as a ladder. Different levels include.
. Being given information - children are given information. Adults make the
decisions.
. Consultation - children are asked their opinions and adults take this into
account when making decisions.
. Adult-initiated - adults start projects and share decisions with children. This is
distinct from child-initiated projects.
. Partnership - children are supported by adults to
come up with idees and set
up projects.
116
Children may be involved in projects in ways which looks like participation but are
not. For example, they or their images may be used to promote a particular
project although they do not understand what is happening. This is manipulative
as children are being used as ‘decoration’. Children may be involved simply
because projects know they should involve them. This can lead to ‘tokenism’
where children are ‘involved’ in a project but they have little ability to influence
decisions.
Different Ways of Participating
Participation may take different forms in different settings. Various things need to
be considered when trying to find a good way of involving children. These include
children’s age, sex, ethnicity, religion and family background. Disabled children
may need special consideration to enable their participation.
There are a wide variety of ways of allowing children to participate. These include
through writing stories and poems, drawing pictures, forming their own
clubs/organisations, playing games, attending workshops, drama, music, using
puppets, sports and taking part in discussions and surveys.
117
• 8.2 Stigma and Discrimination
TNS section iooks at issues.eiatin^>s£
rs(M’Key points about stigma and discrimination are:
1
Stigma is based on beliefs. A person's ®tg^g®®ey'have experienced or
thinks negatively of them becau^
Discrimination occurs when
SS a"(0? noX) on t?e basis ot a stignatising belief.
2
HIV/AIDS leads to stigma and discrimination.
^S5s^sssrn8,he,a*,ocal
4 There are many negative effects of stigma and discrimination.
5. stigma and discrimination go against a -X® > <»
and fairly.
6 There are many actions which can be tahen by individuais and organisations
to overcome stigma and discrimination.
Stigma, Discrimination and HIV/AIDS
Stigma is about beliefs and' attitu^
to
based on negative views of
S^P V
wVjth stjgma and
~se of hVs association with death, sex and
drug use.
Children in other groups
drugs. Many oftbese experience doubie stigma
because they are also more vulnerable to HIV/AID .
Effects of Stigma and Discrimination
118
may result in children lacking access to health care (3.1.2) and education
(4.2.1).
Effects of stigma and discrimination include:
• Fear of members of the stigmatised group.
• Verbal and physical abuse of children.
• Fear of disclosing information, including results of HIV tests. This may mean
that people do not get the treatment they need.
• Reduced self-esteem and confidence among children.
• Children being isolated socially. This can mean they are ‘excluded’ from
society.
• Withdrawal, depression and other psychosocial problems (5).
• Children running away from the place where they are experiencing this. This
may involve them moving from rural to urban areas. This carries the risk of
them ending up living on the street (7.2.3).
The Right to Equality
Children have a right (8) to be treated equally. If a child id treated differently just
because they belong to a different group, they are being discriminated against.
This is against their human rights.
Proposed Action
The following actions can help overcome stigma and discrimination:
• Laws which ensure that children are treated equally and fairly.
• Local advocacy (2.2.1) on behalf of children to ensure that communities
support children’s rights to be treated equally.
• Psychosocial support (5) to children experiencing stigma and
discrimination.
• Allowing children to participate (8.1) in activities and decisions. Children can
then challenge stigma and discrimination themselves.
119
. Programmes must themselves avoid dl^crim'r’gt0 J AIDS^n addition ^hey
not target only Children whose parents have died of AIDS lri addition, y
should not use stigmatising terms (1.1) such as AIDS orphans
120
8.3 Protection from Abuse, Exploitation, Neglect and Trafficking
This section looks at issues relating to the protection of children from abuse,
exploitation, neglect and trafficking. This is part of children’s rights. Other
sections look in detail at participation (8.1), stigma and discrimination (8.2)
and legal issues (8.4).
Key points about abuse, exploitation, neglect and trafficking are:
1. Abuse takes many forms including physical abuse, physical abuse and sexual
abuse. Children may be abused as part of domestic violence, that is violence
directed by men against women.
2. Child sexual abuse is defined as involvement of a child in any sexual activity
before the legally-recognised age of consent. It includes forms of sexual
exploitation (6.2.1), including child prostitution and pornography.
3. Exploitation of children includes harmful forms of child labour (6.2.2),
commercial sex and early marriage. Organisations working with children can
also exploit them. For example, use of their identities to promote projects
without their full understanding can be considered a form of exploitation.
4. Child neglect occurs widely in developing countries as a result of poverty. It
may be difficult to separate deliberate neglect from poverty-related problems.
5. Trafficking is the sale of children for any purpose. It is closely linked to
commercial sex in most cases.
Many actions have been identified which will protect children from these things.
These include:
• Tackling the root causes of exploitation and trafficking, such as poverty.
• Recognising that children are the victims of these practices and that they
need support not punishment.
• Support that may be provided to children in these circumstances includes
counselling (5.2.1), provision of temporary residential permits and protection
to testify in legal proceedings.
• Protecting children from these practices until they reach age 18. Ages of
consent below 18 should not be taken to mean that children under the age of
18 can consent to exploitative practices including prostitution and
pornography.
•
I2l
. Allowing children to jjarticipate (8.1) in
finding solutions to these problems.
. Actions which tackle the negative side of Internet use.
. Legal provisions which allow sexual exploitation in one country to be
prosecuted in another.
. Ongoing research and investigation into these issues.
122
8.4 Legal Support
This section looks at legal issues relating to children’s rights (8). Other sections
look in detail at participation (8 1), stigma and discrimination (8.2) and
protection from abuse (8.3).
Key points about legal issues and children’s rights are:
1. There are a number of international conventions which refer to the rights of
children. The most important of these is the UN Convention on the Rights
of the Child (8).
2. Laws in different countries vary greatly. The constitutions of some countries
include provision for the rights of the child.
3. There are a wide range of laws relating to children in many different countries.
4. However, the existence of a law is not sufficient to ensure that children enjoy
its benefits. People have to know about the law and it has to be implemented
or enforced.
Examples of the kinds of laws that countries have include:
• Clear description of the circumstances in which the state can take over
responsibility for a child. They will then need to find alternate
accommodation (7.3) for that child.
• Laws which allow people to adopt (7.3.1) children. Many of the arrangements
which are made for children whose parents have died are not recognised by
law. For example step-parents and guardians are not always recognised as
having parental rights and responsibilities. Sometimes these can only be
gained by adopting the child or by gaining a court order. Guardians may be
recognised legally if this is stated in a person’s will (5.2.2).
• The age at which a child legally becomes an adult. This is called the ‘age of
majority’.
• Laws which outlaw harmful cultural practices, such as female genital
mutilation.
• Laws which provide for access to health (3.1.2) and education (4.2.1).
In some cases, laws and agreements may be needed between countries to
tackle particular issues, such as inter-country adoption and abduction*.
123
8.4.1 Birth Registration
at inheritance (8.4.2) issues.
A child has a right to an
SS'SunWes. particularly in
—18« -nd school -out this
certificate.
be taken to Increase the number of chUdren having their births
Steps which can
registered include:
—
considerable time and expense.
. Targeting birth registration services at the poorest and most marginalised
people.
. Linking birth registration to immunisation.
fines for late registration and petty
. Removing barriers to registration, such as
bureaucratic rules.
♦ Running Information campaigns aimed at parents and adu.t caregivers
explaining
the importance
importance of birth registration.
plaining the
124
8.4.2 Inheritance
This section looks at issues relating to inheritance that affect orphans and
vulnerable children. Rules about inheritance usually form part of national law
(8.4). Another section looks at birth registration (8.4.1).
Many children in developing countries face problems inheriting their parents’
property when they die. This may be partially due to cultural traditions concerning
property inheritance at death. These may prevent women and young children
inheriting property. Instead, property may be inherited by a male relative of the
father. It is expected that he would then take on responsibility for care of his
brother’s family. However, sometimes relatives may take the property without
taking on responsibility of care.
In addition, there may be cultural taboos about succession planning (5.2.2). It
may be believed that planning for death can cause death. This may be one
reason why few people in developing countries write wills. It is however easy for
people to write their own will using a standard format. This can be used to
appoint a legal guardian in case of parental death. Wills can sometimes be
written as part of memory projects (5.2.2).
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