His no longer a death sentence. That hopeful declaration — which would have been unthinkable even a decade ago — has now become a cliché by repetition whenever experts, physicians, academics and journalists gather to chart progress in fighting the disease and to set goals for the future. But for many people, sadly, that statement is not actually true. There remains no cure for the disease, and not everyone can get access to the anti-retrovirals (ARVs) that have done so much to help so many. This reflects the painful truth that poverty remains a major impediment to good health in the developing and even the developed world.
In fact, in too much of the developing world, people with HIV who contract tuberculosis, for instance, and cannot get swift treatment often have only six weeks to live. Even those whose lives are saved by ARVs must take costly medicines for the rest of their lives and many are forced to battle side effects. So, as we celebrate how far we have come, it is important that we in the global health community take our success as a spur for future innovation rather than a cue for complacency. The truth is that for millions of people in the developing world, HIV/AIDS is just one impediment on the road to a full lifespan and healthy lifestyle.
For many, one of the greatest barriers to improving health is poverty. Simply put, the circumstances into which people are born can dictate their physical well-being for the rest of their lives, unless we can do something to stack the odds in their favor. Low incomes, rudimentary education, long-term unemployment and unreliable health care infrastructures represent exceptionally challenging problems in the developing world. But innovative, sustainable programs linking health to economic empowerment are building stronger communities that are improving both the length and quality of lives. At Project HOPE, a Virginia-based NGO founded over 55 years ago and active in about 35 nations, we are building on years of experience in lowering the barrier to improved health care, including addressing economic constraints and making innovative adaptations to practices in the field.
About 1.2 billion people live in extreme poverty defined as on less than $1 per day. It is well-known that the effects of poor health can decrease economic productivity and undermine the general well-being of families. Billions of dollars in aid have been spent to address this reality, reflecting the fact that global health experts, economists and politicians generally agree that to improve the quality of life for vulnerable populations, one must consider the fundamental relationship between poverty and health.
It Takes a Village
For more than 20 years, Project HOPE has incorporated economic strengthening components into our health focused programs to promote economic empowerment as a means to improved health. Our approaches utilize village or community-level, group-based micro-credit and savings schemes allied with health education programs targeted directly at the individual needs of participants. Through this approach, individuals have made improvements in their health and at the same time bettered their economic situation, which is in itself a key driver of enhanced health and well-being.
Project HOPE began to integrate the village banking micro-credit strategy into our maternal & child health education for mothers in 1993. We found that mothers, even when they knew how to seek medical care or how to properly use medicines, simply did not have the financial resources to do so. Most families in developing countries engage in a variety of economic activities and thus the constant worry of keeping food on the table prevents mothers from focusing on health care for themselves and their children. Additionally, the economic costs of poor health can be significant when mothers are unable to work and the family grows more vulnerable.
Our Village Health Bank model provides micro-loans to empower small groups of women to invest in small-scale businesses and thus generate greater personal incomes. As the groups are trained to operate by themselves, each participant learns new skills and self-respect. During regular group meetings, targeted health education is provided so participants can learn to prevent health problems, and use their new resources to better address them. Each bank also conducts a community activity to promote better health. Examples of successful activities include garbage clean-up campaigns, health fairs, transporting a nurse to weigh and examine small children and identifying locally available nutritious foods. The health component of the program promotes links with existing public and private sector health care services and providers. From its start in Latin America (Honduras, Ecuador, Guatemala, Peru & Nicaragua), the methodology expanded to several African countries (Malawi, Mozambique, Namibia) and Asia (Thailand), and in every case has proven successful in empowering women to improve their family’s well-being.
Margarita Lopez, an indigenous mother of four, led a Village Health Bank in Cruz de Piedra, a rural town in Guatemala. The women’s health talks helped to empower 14 women, who heard for the first time about concepts like “negotiating equality,” self-esteem and basic health issues. Women are often disenfranchised in certain developing countries and have fewer legal rights than men; they have less access to education and career advancement, and the result is that women frequently have low personal self-confidence or belief in an ability to control their lives. Our programs help to address this by offering women opportunities to be successful. Margarita found employment in San Marcos while she continued to lead her group in the Village Health Bank with exceptional energy and focus, successfully lobbying the Mayor of San Marcos to establish a budget for the construction of a quality, high capacity drinking water system. Margarita is viewed by many as a champion of her indigenous community and she credits the Village Health Bank for teaching her the power of organization and representation, lessons that she is teaching others in Cruz de Piedra today. Her experience illustrates the qualitative impact for women who participated in the program and in Margarita’s case, the huge gains for an indigenous community led by an indigenous woman.
Project HOPE has also implemented a wide-spread community-level group based savings mobilization program (Village Savings & Loan) in Mozambique, Namibia and South Africa that leads to improved economic development of rural participants in a sustainable manner. By training and organizing men and women to mobilize very modest amounts of savings over time, financial resources can be pooled to preserve capital for times of need. Additionally, the funds can be collectively invested into group owned income generation activities or loaned to individual enterprises while paying an interest return to the participants. Thus, these savings groups stimulate preservation of financial resources and generate additional income. As the community groups are trained to be self-managed, for the model does not require investment of external capital, over time the external support can be withdrawn, leaving a sustainable community network. There is no guarantee of repayment and no assets are taken as collateral, so savings groups use their knowledge of the individuals and the influence of a peer-group environment. We’ve seen repayment rates exceeding 95% since inception, partly because people are careful not to besmirch their good credit as there may be few other options to access loans.
In Project HOPE’s model, additional training and education are included to help address needs of the community such as HIV prevention and care and support for orphans and vulnerable children. Lastly, because the groups are organized as a network, it is easy to establish linkages with other programs such as food security or agricultural development to enhance the overall household and community well-being. This savings-based model is a successful approach to economic strengthening in rural environments where there are limited market activities for micro-credit and therefore is broadly replicable.
Consider the case of the Ciseho project in Namibia, a Project HOPE village savings and loans group. It used its savings to buy food, which they then shared amongst the 106 orphans and other vulnerable children who come to the soup kitchen after school hours. The project is now registered with the Ministry of Gender Equality and Child Welfare and the Ministry of Trade and Industry. It also receives support from the head of the Town’s Zoning Committee, who has been appointed as a member of the Ciseho project’s Board of Directors. The Zoning Committee has already tentatively allocated land for the Ciseho project to build a permanent structure to operate the center. Members of the project are continuing this economic empowerment approach and now run a kindergarten and a soup kitchen to serve more than 100 children in Katima Mulilo. In Mozambique, groups have successfully pooled their resources to start a farm to grow produce to provide food for the vulnerable families in their village, and to sell vegetables to buy school materials and second hand clothes for orphaned children.
Comprehensive Support for the Care of AIDS Orphans
The majority of orphans and vulnerable children in Africa are cared for by family members. Many of the participants in our economic strengthening activities were caregivers of orphans who came to us to help them deal with the economic costs of their expanded families, so we adapted our approach to include comprehensive care and support to improve the well-being of vulnerable children in Mozambique, Namibia, and South Africa. We train and educate caregivers to develop skills that will enable them to better understand the needs of children across multiple areas of child development in accordance with national standards (many countries establish their own guidelines and technical recommendations in addition to international standards issued by UNICEF and USAID), economic strengthening activities with caregivers so they can generate additional financial resources and alleviate economic burdens of their households; and linking children with a community network of volunteers and support organizations to provide support, peer-counseling, training and help them gain access to needed services. With greater financial resources and expanded self-sufficiency, caregivers can better provide for the needs of their families.
Emilia, a mother of five and caregiver to three children under the age of 18 in the Oshikoto region, joined the Project HOPE Ombundu Group in 2012. She became secretary of the group and through training, she learned minute taking and communication. “This program has really changed my life,” she said, recalling the child development training she received which gave her a deeper understanding about her children’s needs and how to nurture their emotional well-being. She discovered the importance of listening to her kids to help build their self-esteem. Emilia now also understands health issues relevant to her teenage children and talks openly to them about the dangers of HIV and how to protect themselves. Orphan children are commonly ostracized when they lose their parents, which is a time of great emotional upheaval. It is important to help them regain their self-esteem and optimism for a positive future. Listening to children and allowing them to have a voice is a recommended and crucial practice.
Improved Quality of Life
Internal evaluation and external studies, carried out by independent consultants who conduct research and interview participants before results are shared with the donor funding the project, have shown that Project HOPE’s economic strengthening programs produce substantial improvements in individual and group economic outcomes as well as significant increases in health knowledge and behaviors. We have catalogued the following:
35% average increase in reported income after a year of VHB participation
20% average improvement across multiple indicators of economic status in VHB programs
Personal assets and savings doubled
25% increase in quantity of meals consumed
30% reduction in length of hunger period experienced
15% reduction in liquidation of household assets
10% average improvement in knowledge of HIV prevention
15% average improvement in accessing health services when needed by children
VSL participants report a build up of household assets and a 20% return on their savings as investment income
Improvement in child well-being has averaged over 15% across 8 different districts in Namibia & Mozambique in our OVC programs
In Project HOPE’s programs focused on orphans and vulnerable children, increased income and financial resources generated allows caregivers to purchase school uniforms, pay school fees, buy an increased quality and quantity of food, and improve access to medical care. When combined with the increased knowledge about parenting and child-care issues across multiple domains of need, orphans and vulnerable children are shown to receive better care and support and experience an improvement in their overall well-being.
One of the added benefits of our approach is that the people we help experience improvements across the whole spectrum of human experience. They don’t just have healthier lives: they have better lives.
The experience of working in a successful group environment, actively handling financial affairs, exchanging views and information, and proactively resolving problems enables marginalized people to overcome barriers they face and become more active participants in society. Although Project HOPE’s economic empowerment programs directly serve participants, entire communities benefit. We have seen over 100,000 participants in economic empowerment programs since their inception and over $35 million in loans provided, with repayments rates exceeding 95%, and three sustainable successor local NGOs established.
Juliazarda Fransico Jemo from Maxixe in Mozambique has a remarkable story of recovery. She was widowed after her husband passed away from HIV, and she too was found to be HIV positive. Fortunately, their child was not. She was able to access treatment through the Community Care HIV/AIDS Services Strengthening Program (CCP) program, but when she recovered her health, she had no means for income and no opportunities to rebuild her life. Fortunately, she heard about the women’s savings group in her community of Maxixe that was formed by the Project HOPE sub-grantee Kukula. This group welcomed her, and through them she was able to save, access small loans to start up a business trading second hand clothes and bedding. As she is a hard worker, her business became successful, and she was able to rebuild her life. She was so thankful for prosperity that she adopted an orphaned child, and is now building an improved house for her thriving family.
Saving Lives By Preventing TB/HIV Co-Infection
Infectious disease experts are gravely concerned that the deadly link between Tuberculosis (TB) and HIV could overshadow the successes of the last decade in the fight against HIV/AIDS, particularly gains made by the use of anti-retrovirals. Educating communities about TB detection and TB/HIV co-infection is crucial not only in Africa, but in Central Asia and other regions as well. People with HIV are now surviving thanks to lifesaving medicines, but sadly, too many people with HIV die from TB. This is a particularly wrenching scenario because it is preventable. Early diagnosis and treatment can save lives. In Namibia and Malawi we’re working with partners to address TB/HIV co-infection by promoting early diagnosis and supporting treatment adherence.
The World Food Program (WFP) provided funding to Project HOPE in 2006 for seven years that enabled Project HOPE to provide food support for TB patients and their families in Tajikistan. The WFP had determined that TB patients had some of the highest rates of poverty, and our project targeted multiple levels: providing food to people with the greatest need, while supporting TB patients and their families during TB treatment, and providing an incentive for patients to complete their treatment. Over a four year period, ending in 2012, we provided food support for over 42,000 people including over 15,580 TB patients and over 27,000 family members. In 2011, treatment outcomes in 11 districts where patients received food support had a default rate of 2.4 percent, whereas in the country as a whole the default rate was nearly double, at 4.5 percent. The food program saved lives and patients remained committed to treatment.
For millions of people, life will improve only with innovative development models – the next generation of empowerment approaches that will not only ease the plight of vulnerable communities but can improve overall health to diminish the incidence of diseases including HIV/AIDS.
Plotting Better Health for Future Generations
On his first major African tour as US President last year, Barack Obama acknowledged that creating sustainable health solutions for Africa’s future generations presents enormous challenges. However, he argued that the U.S. must do more than just deliver antiviral drugs, the nation must ask how to create a sustainable health infrastructure in these countries.
“I think everything we do is designed to make sure that Africa is not viewed as a dependent, as a charity case, but is instead viewed as a partner; that instead of chronically receiving aid, it is starting to get involved in trade, get involved in production, and over time is going to be able to feed itself, house itself, and produce its own goods. And that’s what Africa wants,” President Obama said. That is a question that is relevant not just to Africans but to millions across the developing world. It is a question with which Project HOPE and fellow health NGOs wrestle with everywhere we work, from the AIDS ravaged nations of Africa, to factory floors where we educate Cambodian women about health, to the still rudimentary medical systems of post-Soviet Europe, and to efforts in rebuilding earthquake-scarred Haiti.
It cannot be stressed enough that the global health community will be engaged in the fight against HIV/AIDS for years, if not decades. By being flexible in our approach, and by pursuing both clinical and developmental strategies that strengthen vulnerable communities and the health infrastructures of the developing world, we may speed the day when that mantra “HIV/AIDS is no longer a death sentence” actually rings true.