Preventing and Coping with HIV/AIDS in Post-Conflict Societies: Gender-Based Lessons from Sub-Saharan Africa

The REACH Project, Kapchrwa District Eastern Uganda

Narrative By Turyatemba Odongo Caroline, BA.ED Hons, BSH

Initiation and Development of the REACH Project

The Sabinyi Community, Government and UNFPA’s concern over the risks and hazards associated with female genital cutting (FGC), the poor reproductive health (RH) care, health service delivery in Kapchorwa district and the need to see fewer women/girls undergo the practice of FGC led to the development of the REACH Project led to the birth of the REACH Project.

Project Setting

The REACH Project is a community intervention and at the same time a forum for the local community (parents elders, political leaders, health workers, surgeons and guardians, and the youth) to share information on aspects pertaining to the FGC practice.

Women and the female adolescents were initially viewed as the main beneficiaries. Nevertheless the rest of the community members also concerned, benefit from the improved RH service situation in the district.

Government and the human rights activists (local and international) and the UNFPA are also indirect beneficiaries because they are interested in seeing more women / girls refrain from undergoing circumcision.

Funding for the REACH Project

Through the government of Uganda, UNFPA committed financial assistance to the REACH Project initiation and implementation process. The population secretariat (POP SEC), the Kapchorwa district administration and project management respectively, implemented the project.

The goal of the project:

The goal of this project is to enhance the reproductive health conditions of all people of Kapchorwa and to discard the harmful practice of female genital cutting while promoting cultural values among the community of the district. It also had the following short-term objectives:

To have established the persistent reasons for girls and women to continue the practice of FGC

To actively sensitize the target groups about the harmful aspects of FGC at least 30% of the target group in the district

To sensitize TBAs at least in the district on the harmful aspects of FGC and to enhance their basic delivery skills and performance.

To improve the quality of RHC and FP services in the four sub-county health units (delivery points) and in the maternity wing of Kapchorwa hospital.

To have contributed to making the district population coordination structures in Kapchorwa functional and to strengthen its role in population and RH advocacy. Later the planning component was introduced.

The strategy to achieve these goals

Although the female target group who were the recipients and providers of the FGC service seemed to be those to be targeted to get away from the practice, it was soon realized that the majority of those who continued on to be circumcised was a result of social pressure from the old population. These could be parents-in-law, relatives or neighbors. The potential target group then became the elders, religious leaders, parents-in-law, youth and the uncircumcised women recently married.

In order to achieve the above objectives the following strategies and activities were planned:-

Related Activities

These activities are sub-divided into 3 steps in order to show how each group of activities led to the others.

Step 1

Review of the FGC practice in general and documenting the failure of previous attempts

Bringing together of all interested parties to have an open (non-judgmental) debate on FGC

Identification of the potential program mangers and consultants in the community and the preparation of the draft document with MOH and POP SEC

Securing a consensus in the community by discussing this document with those previously involved in its initiation and endorsing the proposed objectives.

Launching of the program activities

At this point no suggestion to discard or abandon the culture was made. Indeed, emphasis was placed on identifying those positive aspects of the non-prescriptive nature and this appealed to the elders and clan leaders and created a conducive environment for accepting the principle of discussing the practice publicly in the first place. This paved the way for future activities this time with the full blessing of the elders and clan leaders.

Step 2

Adopting the FGC concept for being less judgmental of the community

Sensitize the community and in particular, the elders, women’s and youth groups on the harmful aspects of FGC

Promote girl’s education in the district and add a component on harmful aspects of FGC in the school health education curriculum of upper primary and secondary schools

Resolve that even the symbolic initiation of girls below the age of 18 years, without their informed consent should be done.

Discourage the licensing of circumsicors and encourage them to seek other kind income generating activities.

Involve religious institutions, district heads of department s and the Sabinyi Elders Association in the sensitization program through seminars and workshops held in the district and village levels.

Carryout more research on the views of parents, elder’s youth and surgeons and the use of these results to develop IEC materials to discourage families from resorting to the practice.

Improve and expand reproductive services in the community.

Step 3

Organizing awareness creation seminars and carrying out advocacy activities aimed at conservative groups such as elders and clan leaders, and the potential change agents such as peer educators, health workers and women groups. This involved developing FGC specific IEC materials and using existing ones; building coalitions between project management and Sabinyi Elders’ Association; and networking among education institutions, religious groups, politicians, health institutions and community leaders. This was meant to build partnership with key groups in the community to rally their support, legitimize the purpose of the program and create a conducive environment for change.

Targeting and mobilizing the young people in particular (age bracket 12-24, in schools and within the community) equipping them with information and facts about the harmful aspects of FGC and supporting them in questioning and challenging the practice. Two groups of youth mobilizers were called upon: the community based Agents (CBAs) and sub-county contact persons (SCPs) at the community level and peer educators (EPs) to reach out to school going adolescents and youth

Training TBAs to enhance their reproductive skills and to increase their awareness about the associated risks of the practice

Renovating four health units and the maternity wing of the district hospital and equipping them with basic MCH/FP kits. This contribution is meant to strengthen the RH services given the poor conditions of the maternity wing and lack of basic MCH/FP kits.

Proposing and supporting the organization of a cultural day for the district. This day is meant to:

Reassure the community about their cultural values

Be an advocacy strategy to strengthen the sense within the community that positive cultural values can be promoted while negative one can be changed or replaced

Be a socially suctioned demonstration event that would convince the community to discard genital cutting per se and to replace it with more symbolic ritual – such as giving a cow, goat bracelets after the rituals of feasting and dancing- to mark the passage from girl hood to womanhood. The date was proposed to be November 30 of every year with the aim of eventually replacing the formal opening of the circumcision season, which takes place on December 1st.

Support the district in setting up a population coordination structure to ensure sustainability of the program in the medium and long run.

Project Implementation

The project was /is implemented by project management of Kapchorwa district, coordinated by the POP SEC Ministry of Finance and Economic Planning and Executed by the Kapchorwa district administration.

Gender Consideration of the Project

The gender considerations in this project were very crucial this was because the main proponents of the FGC were in both genders. The custodians of the FGC practice were the male clan elders and the implementers (the circumcision surgeons) who lived off the economic benefits of the practice. Both the above sections of the community including the women, youth and district health care worker had to be included in the process.

The impact of the project

This can be seen in the outcomes of the project both expected and unexpected.

The Expected outcomes included:

All the above contributed to a strong and cordial relationship between the health programs and peace building efforts during the FGC resolution and elimination process. These factors also contributed to the successes of the project as demonstrated in the outcomes above.

However the impact was less for the out-of-school adolescents and dropouts, mainly because they were not directly targeted during the pilot phase.

Evaluation and Monitoring of the REACH Project

An independent evaluation was commissioned in February 1997 to assess the program's performance, evaluate the impact and assess the relevance, sustainability and replicablity of the REACH project as a concept model.

The evaluation used qualitative and quantitative methods to ascertain the performance and impact of the program. It concluded that the project had made a significant impact and brought a positive change in FGC perceptions. Project impact, the evaluation concluded was considerable in the sub-counties (of Kaserem, Kabai, Sipi, Swam and Binyinyi) where the program was intensively operating.

Way Forward

The lessons learned and recommendations that I would like to share with those working at the local level on similar projects as well as make to African governments, their policymakers and the International community including USAID and other donors include the following:

Replicating the REACH model is therefore, not only possible but is also likely to produce a positive outcome in a reasonably short period of time on such a sensitive issue.

Devising a similar program in other countries, however, should first and foremost reassure the community of the integrity of their cultural identity, and separate the practice from the culture per se so that the practice can be singled out for questioning.

Again, questioning any practice that is deeply rooted in tradition, should originate from within the community, through their institutions that are considered having authority on values and should not be perceived as a prescription or a recipe "handed down" to them from a "better culture".

One of the premises of REACH concept is that there is no such thing as better cultures. Cultures vary depending on the state of knowledge, development and technology. Yet they are all equally valuable to their members.

Disseminating the REACH model and the process of project initiation and development would also help other countries and communities replicate this successful experience of structurally discarding FGC (HIV high-risk behaviour) and other practices harmful to reproductive health.

Also to use grassroots or district projects like REACH as entry points in the mitigation of HIV/AIDS activities.

According to Francios Farah (whose writing consists the part of this narrative) Uganda is now one of the very few countries that are in a position to setup a realistic and achievable timetable for the eradication of FGC by 2000 or 2002. REACH is committed to achieving this objective with the support of UNFPA.

Personal Testimony

As a frontline health care worker in a medical research institution focused on HIV management in the city, the REACH Project provides one of the kinds of referral centers required at district level. This program provides for us not only a medical referral center, but also a psychosocial support system to which to return a client, why?

It is sustainable because it has grown into the very fabric of the Sabinyi people. HIV/AIDS management slots in comfortably into the district health, MCH and FP services without raising stigma issues associated with HIV/AIDS services as perceived in the utilization of separate HIV/AIDS services.

Most grassroots HIV/AIDS service providers are easier accessed as referral persons who can conduct follow up on the patient unlike the field workers whose offices maybe national or sub regional. This reduced the cost on the individual and their caregivers involved with travel to and from JCRC, which is about 300 or more km away for management of opportunistic infections. This also provides for the management of the patient within their own family / community setting which they may find more comfortable.

It is very stressful to manage a patient who comes from a setting lacking such facilities as provided in the REACH set up. However, this is the majority of our patients. In most cases in as much as there may be information available the practicability of the utilization of this information makes on feel they have hit a brick wall. As such both health caregiver and patient fell at a loss but have to settle for what is available within the limited resources.

In my work with Preparation for AIDS Vaccine Evaluation (PAVE), this program was more geared towards collection of scientific and psychosocial data for the purposes of preparing for an AIDS vaccine trial. Here there was some limitation in interacting with the community as a whole and as such we got put ourselves sometimes into dangerous life threatening situations when dealing with some post conflict community of persons. These crisis situations mainly came up because we were not conscious enough to deal with the deeply rooted cultural norms of that particular community. Now we know better than that, but we have lost in terms of cost in time and relationship

LIST OF ACRONYMS

AIDS      Acquired Immune Deficiency Syndrome

CPs       Contact Persons

DPO       District Population Offices

JCRC      Joint Clinical Research Center

POP SEC    Population Secretariat

MCH       Maternal and Child Health

FGC       Female Genital Cutting

GOU       Government Of Uganda

HIV       Human Immuno-deficieny Virus

TBAs      Traditional Births Attendants

TOTs      Trainer Of Trainers