Increasing Institutional Capacity of RH and
HIV/AIDS NGOs for Linked Response
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Ethiopia

Hiwot Ethiopia

Pro Pride

With a total population of 72,420,000 , Ethiopia is one of the most populous countries in Africa after Nigeria and Egypt. It is also one of countries most seriously affected by HIV/AIDS in the world. About 1.5 millions Ethiopians are living with HIV/AIDS by the end of 2003. Of these, 51.3% (770,000) are women aged 15-49, 8% (120,000) are children below age 15 (Source: UNAIDS/WHO Epidemiological Fact Sheet - 2004 Update).

The RH indicators in this country are poor. There is high maternal mortality rate (871/100,000 live birth), low family planning coverage (CPR approximately 8%), and low coverage of RH services (ANC, institutional deliveries). Women are exposed to several health and social problems through early marriage, abduction, violence, female genital mutilation etc .

The challenges faced include lack of capacity, in terms of skills, human resources, infrastructure and facilities, equipment and materials, deeply rooted poverty, rapid population growth with slow increase in food production and drought, impact of HIV epidemic on national economy, health, life expectancy, social and socio-cultural structure. There is also a need to create a more concerted, well-coordinated effort to ensure program sustainability and efficiency, and to increase community involvement (Source: Dr. Getnet Mitike, 2005. Presentation during dissemination seminar on liked response to RH and HIV/AIDS, Addis Ababa. 19 August 2005).

1. Hiwot Ethiopia

Organizational Profile

Hiwot Ethiopia was established in 1995 as a small club by 14 young men and women which had been terrified by the epidemic of HIV/AIDS and the death of thousands including their peers. ‘Hiwot’ means ‘life’ – Nothing is worthwhile before life. The mission is to contribute towards forming a generation that is full of hope, leads a responsible and healthy sexual reproductive life free from HIV/AIDS, STDs, unwanted pregnancy, sexual molestation and addiction.
Display of contraceptives of HIWOT's
Youth Centre

The objectives of Hiwot are:

• to prevent the prevalence of HIV/AIDS and other sexuality hazards of all young people;

• to enable all young people to demand for sustainable and affordable SRH information and services;

• to contribute to the best and possible outcomes of youth concerned policies and programs at all level;

• to increase the youth participation in all organizational development and program implementation; and

• to enable young people to be self-supportive and self-reliant

The clients of Hiwot include HIV positive persons, orphans, in-school youths and dropouts. Hiwot provides financial, material and technical support to 15 youth clubs for them to deliver SRH information and services to young people age 10-24. Hiwot runs different awareness raising programs through seminars, coffee ceremony, IEC materials etc. It also works with parents, community leaders, government officials, and policy makers to encourage them to participate in youth RH program.

Action Plan Implementation and Achievements

Coffee discussion and music and drama groups have always been Hiwot Ethiopia’s strategy for behavior change communication. In this project, building on its strength, Hiwot Ethiopia held 12 discussion sessions on PMTCT and FP with the community members during 4 coffee ceremonies, reaching 200 males and 170 females. It also reached 2400 men and 2100 women in two sub-cities through its drama and music group.

The project has enabled Hiwot to identify and integrate missed opportunities that could have been linked in addressing both HIV and RH information and services. FP counseling as well as referral for VCT and FP services is now offered as a package. In view of the vulnerability of young people especially girls to HIV/AIDS and the risk of early sexual debut, marriage and pregnancy, Hiwot set up a referral linkage with Mary Stoppes, Family Guidance Association of Ethiopia (FGAE) and African Services for FP and VCT services. 52 males and 87 females were referred for VCT and FP services.

The linked response has also shaped the organizational outlook in framing the peer discussion by linking HIV/AIDS and RH, as guiding the discussant to demand for linked services. 44 youth dialogues sessions were conducted reaching 625 males and 695 females. The dialogues focused on male involvement in FP access and HIV/AIDS prevention and being supportive of their partners.

Hiwot organized a public discussion on ‘male involvement on the issues of women’s sexual and reproductive health’, attended by 265 males and 323 females. The organization had similar experience in advocating for male involvement in the past but the experience had been limited – the ‘how’ and ‘where’ male can involve in a linked service were not addressed. The advocacy conducted in this particular project has paved the way for understanding, identifying and addressing missed opportunities to gear male involvement in better RH services and HIV/AIDS prevention. This activity appeared on the Addis Ababa City TV Program. Linked response was highlighted.

Hiwot also organized a public discussion session to advocate for the Sexual and Reproductive Health (SRH) including HIV/AIDS rights and needs of HIV positive women. This program was organized in such a way that participants understood the concept of linked response in line with the basic rights of RH. 295 males and 270 females attended the session.

Linked response also triggered new ideas. Young boys involvement and active participation in gender sensitive RH/HIV/AIDS programs would have a paramount effect in promoting RH. Therefore, Hiwot formed a young boys’ model group called ‘males for females’ where 40 young boys would be at the forefront to fight gender violence that affects both sex. They would advocate for mutual and shared responsibilities in caring for and advocating for women and girls’ SRH. The young boys had realized that their involvement would nurture health seeking behavior and positive practice along with understanding and respecting the rights stipulated in various legal framework. Hiwot Ethiopia successfully mobilized funds from Save the Children Sweden for this activity.

The Impact: Enhanced Capacity

The linked response project has resulted in some positive changes in the organizational and staff, program and service, as well as individual and community levels:

Organizational and staff levels:
Linked response is mainstreamed in Hiwot’s programs and activities. The concept is shared and embraced by everybody in the organization. It has motivated staff members that they are able to produce maximum output given limited resources. Their capacity in monitoring and evaluation, and financial management and budgeting has improved.

Program and service levels:
The project has enabled Hiwot to identify and integrate missed opportunities that could have been linked in addressing both HIV and RH information and services. It also triggered new ideas on linked interventions. In this case, the ‘males for females’ groups.

The establishment of referral linkages has enabled a more comprehensive services delivery.

Individual and community levels:
Community members, particularly young men and women, benefited from linked response. Their awareness and knowledge on VCT, FP and HIV/AIDS has improved. The project has also received good response. There is active involvement of men and women, particularly HIV positive women, as well as young people to demand for and access VCT, FP and other RH information and services.

Key Challenges

Due to the current political situation in Ethiopia, Hiwot encountered some difficulties when implementing this project. For example, the public discussion session was hampered by the election in Addis Ababa, and had to be postponed. It finally took place in August 11, 2005, a week before the dissemination seminar. Also, it was difficult to solicit support from the local government units because the government was undergoing restructuring after the election in May. The timing of the dissemination seminar (19 August) is appropriate because at this time the situation is much more stabilized. During the dissemination seminar, the leaders from the idirs group and local government units more than once expressed their interest in linked response. They re-emphasized that the concept of linked response should not just stop there. It should be brought to the grass root levels. They were concerned on what are the problems encountered during implementation, and what facilitating conditions are needed for linked response. Since everybody in the community is a member to the idirs group, idirs is the best agent for linked response. It is important to note that Hiwot Ethiopia keeps the local government informed of its activities by quarterly reports.

The rooted cultural attitudes and norms and practices in the community were also a challenge in increasing male involvement in FP/RH. In addition, initially the expectation from the community was very high. They expected incentives from the project, which was a burden given the tight budget. Therefore, Hiwot utilizes its community conversation team, which composed of representatives from other youth organization, women organization, idirs group, youth clubs, peer promoters to solicit support from the community. Obviously Hiwot Ethiopia has successfully overcome this challenge given the number of people it has reached.

In the effort of expanding its referral network, one of the major challenges encountered is that not all service providers and facilities are youth-friendly.
Even if they are, they are not located within the proximity of Hiwot’s target area. Nevertheless, Hiwot tries to strengthen its existing referral channels.

Lessons Learned

Hiwot realized that it is important to work with Idirs (Community based organizations) to reach the grass root community.

By developing understanding and community responsibility and commitment on RH and HIV/AIDS, the community members have began accepting PLWHA.

The Way Forward

Hiwot is convinced that linked response is an effective way of implementing programs with minimum resources and maximum outputs. Hence, it has begun mainstreaming the concept to all programs, and will continue to do so. For example, in a project funded by Save the Children Sweden, Hiwot trained 40 parents on RH, HIV/AIDS, PMTCT, and communication skills. Community conversation was conducted in a way to increase participants’ knowledge on RH and PMTCT, based on the concept of linked response.


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2. Pro Pride

Organizational Profile

Established in May 1995, Pro Pride stands for empowering disadvantaged individuals, families and communities and helping them actualize their latent potentials. The organization believes that given the necessary conditions and opportunities every person has the potential to be self reliant.

A young mother and her baby at the clinic of Pro Pride

Pro Pride operates in 3 areas: Merkato, Entoto and Mesalemia. The major program components of Pro Pride include:

1) Community based health care (CBHC) – supported by two medium level clinics, focuses on reproductive health, environmental health, IEC production and distribution, vital information gathering and community capacity building;

2) Non-formal education – provides (a) pre-school education to children aged 4-6, and (b) basic education to children aged 7-14 who are out of any school system because of poverty;

3) Cultural promotion – promotes development-oriented culture, and brings attitudinal and behavioral change among community through newspaper and magazine production, drama show, exhibition, radio program and film production;

4) Livelihood promotion - carries out activities focusing on improving household livelihood, which include basic business skills training and credit services;

5) Environmental upgrading – maintains clean environment, through activities such as access road construction, drainage construction and potable water point erection.

HIV/AIDS and gender are cross-cutting activities. Pro Pride promotes rights-based approach, encourages the involvement of the community and other concerned bodies’ in addressing gender issues. HIV/AIDS related activities include community sensitization on HIV/AIDS and STD, condom promotion and distribution, peer education, counseling, care and support.

Action Plan Implementation and Achievements

Before this project, Pro Pride’s clinics had already been providing both RH and HIV/AIDS services, including medical consultation, FP, antenatal and postnatal care, home delivery, immunization, STI, VCT, referrals for PMTCT and laboratory examination. However, the services were compartmentalized. For example, client who came for STI service would receive only STI service, and client who came for VCT service would only be given that service. There was no conscious linkage between the two services. In this project, services were offered as a package, rather than a separate entity.

The risk of contracting HIV by people infected with STI particularly with genital ulcer caused by herpes, chancroid, or syphilis increases as high as 300 fold. Previously, STI and HIV/AIDS counseling were offered separately. In order to reduce the vulnerability of people infected with STI to HIV/AIDS, Pro Pride provided STI treatment to all STI infected, particularly those who were HIV positive clients. Clients who were STI positive were encouraged to take VCT services, and vice-versa. In this project, out of 17 clients who were STI positive, 12 had already known that they were HIV positive. The remaining five were tested for HIV and all found negative. All received medication for STIs and were given advice to avoid re-infection. Pro Pride also provided STI counseling through its community health agents at health posts, and strengthened the existing referral network for services. 18 STI cases were referred to Pro Pride clinic and government health institutions.

In order to reduce the vulnerability of women and children to HIV infection, Pro Pride linked the VCT unit to the FP/MCH unit. Both units were also linked to the external health institutions for PMTCT services. Health professionals were trained on linked response. Now all FP and MCH clients receive both STI and HIV/AIDS counseling. During the action plan implementation period, 281 antenatal care (ANC) attendees were counseled and tested for STIs, 4 were found positive. The husband of one of these clients also came for the test and found positive. Treatment was given. In addition, out of 151 pregnant women counseled on HIV/AIDS, 30 decided to take the test. Of these, 3 were found positive. They were referred to the Black Lion Hospital for PMTCT program. Obviously Pro Pride had shifted its focus from focusing on one issue to addressing multiple issues, by relating RH and HIV/AIDS.

At the community level, Pro Pride expanded the involvement of peer groups and other volunteers to provide home care services to PLWHA. A 3-day refresher training on the concept of linked response and home care services were provided to 15 women drawn from the community based organizations (CBOs) and the CBHC. Pro Pride also expanded the peer groups to disseminate information on FP, STI, HIV/AIDS and other RH related harmful practices. Peer education is a proven effective strategy to influence positive behavior change. 435 males and 179 females in the community received the IEC materials.

Apart from this, recognizing that care and support activities are risky and demanding tasks that require time and patience and in most cases result in dropouts and burnout, Pro Pride thought volunteers needed public recognition and encouragement to continue such an important work. A social event was organized to promote voluntary work and to motivate individuals, families and communities’ involvement in care and support. It was the first social event organized for volunteers.

Before this project, Pro Pride has already set up linkages with the Ministry of Health (MoH) and Addis Ketema Health Center for different health related issues. However, the linkages were not strong. In this project, a formal referral linkage with the Addis Ketema Health Center for PMTCT, ARV and Opportunistic Treatment (OI) was formed - Formal as there is an agreement signed, and counter-referral between Pro Pride and the health center. Pro Pride also managed to mobilize additional resources. Pro Pride now is able to provide free VCT and STI treatment to its clients. Nevertheless, it is a challenge to sustain free service delivery to clients.

Community leaders at the dissemination seminar

The Impact: Enhanced capacity

Organizational and staff levels:

To Pro Pride, this project has created a holistic perspective of individual’s RH needs, as interconnected with HIV/AIDS and vice-versa. It has changed the way Pro Pride works. Linked response is mainstreamed in Pro Pride’s programs and services.

The Board and top management of Pro Pride have provided strong support to this project in terms of time, resources and expertise. Staff commitment and readiness to implement this project are also critical success factors. There were also structural changes in the organization (linking VCT and FP/MCH units), and change of values recognizing volunteers’ contributions.

Program and service levels:

Now, the concept of linked response is reflected in Pro Pride’s programs and services. Programs and services are offered as a package, rather than a separate entity. Pro Pride is also able to provide better services through referral linkages with the government hospitals.

Individual and community levels:

The project has successfully reduced the vulnerability of people infected with STI to HIV/AIDS. It has also reduced the vulnerability of women and children of HIV infections. PLWHA and their family members also benefited in the home care visits as a result of the expansion and involvement of peer groups and volunteers.

Key Challenges

Although Pro Pride is now able to provide free VCT and STI treatment to its clients, it is a challenge to sustain free service delivery to clients.

There are also cultural barriers to overcome. The influence of men on the decisions of women on RH related issues is dominant.

Drop out of volunteers and burnouts are also hurdles to the delivery of services.

Lessons Learned and Recommendations

Pro Pride has learnt that commitment of Board members, senior management and other program staff is critical for successful program implementation. Linking with different stakeholders has enabled Pro Pride to respond to the problem of HIV/AIDS and other RH issues in a more comprehensive manner. Men’s influence on the decisions of women on RH related issues is strong and that gender sensitivity does affect the success of HIV/AIDS mitigation and other RH interventions. Appropriate motivation strategy should be in place to address problems of dropouts and burnouts of volunteers.

The Way Forward

According Pro Pride, the linked response project should be scaled up into a wider context to improve the quality of care with the existing facilities and staff with minimum resources. Advocacy work should be done to promote the concepts and importance of linked response and reorientation of health services in Ethiopia.